PartIVExerciseInterventionsbyBodyRegion

Chapter14.TheSpine:Structure,Function,andPosture
Introduction
Postureisalignmentofthebodypartswhetherupright,sitting,orrecumbent.Itisdescribedbythe
positionsofthejointsandbodysegmentsandalsointermsofthebalancebetweenthemuscles
crossingthejoints.41Impairmentsinthejoints,muscles,orconnectivetissuesmayleadtofaulty
posturesor,conversely,faultyposturesmayleadtoimpairmentsinthejoints,muscles,and
connectivetissuesaswellassymptomsofdiscomfortandpain.Manymusculoskeletalcomplaints
canbeattributedtostressesthatoccurfromrepetitiveorsustainedactivitieswheninahabitually
faultyposturalalignment.Thischapterreviewsthestructuralrelationshipsofthespineand
extremitiestonormalandabnormalpostureanddescribesthemechanismsthatcontrolposture.
Commonposturalimpairmentsandgeneralguidelinesfortheirmanagementaredescribed.Specific
exercisesforthevariousbodyregionsarehighlightedinthischapterandaredescribedindetailin
thesucceedingchaptersinPartIVofthetext.Chapter15describesthecommonpathologies
associatedwiththespineanddetailsmanagementguidelines,andChapter16describesspinal
exercisesandmanualinterventionsindetail.

StructureandFunctionoftheSpine
Structure
Introduction
Thestructureofthespinalcolumnconsistsof33vertebrae(7cervical,12thoracic,5lumbar,5fused
sacral,and3or4coccygeal)andtheirrespectiveintervertebraldiscs.Articulatingwiththespineare
the12pairofribsinthethoracicregion,thecraniumatthetopofthespineattheoccipitalatlas
joint,andthepelvisatsacroiliacjoint(Fig.14.1).
Figure14.1.(A)Lateraland(B)posteriorviewsshowingthefiveregionsofthe
spinalcolumn.
(FromLevangieandNorkin,14p.141withpermission.)

FunctionalComponentsoftheSpine
Functionally,thespinalcolumnisdividedintoanteriorandposteriorpillars(Fig.14.2).14
Theanteriorpillarismadeupofthevertebralbodiesandintervertebraldiscsandisthehydraulic,
weightbearing,
[Figure14.1.(A)Lateraland(B)posteriorviewsshowingthefiveregionsofthespinalcolumn.]
[Figure14.2.Spinalsegmentshowing(A)theanteriorweightbearing,shockabsorbingportion,
and(B)theposteriorglidingmechanismandleversystemformuscleattachments.]
shockabsorbingportionofthespinalcolumn.Thesizeofthediscinfluencestheamountofmotion
availablebetweentwovertebrae.14
Theposteriorpillar,orvertebralarch,ismadeupofthearticularprocessesandfacetjoints,which
providetheglidingmechanismformovement.Theorientationofthefacetsinfluencesthedirectionof
motion.14Alsopartoftheposteriorunitaretheboneylevers,thetwotransverseprocesses,andthe
spinousprocesstowhichthemusclesattachandfunctiontocauseandcontrolmotionsandprovide
spinalstability.

Figure14.2.Spinalsegmentshowing(A)theanteriorweightbearing,shock
absorbingportion,and(B)theposteriorglidingmechanismandleversystemfor
muscleattachments.

MotionsoftheSpinalColumn
Motionofthespinalcolumnisdescribedbothgloballyandatthefunctionalunitormotionsegment.
Thefunctionalunitiscomprisedoftwovertebraeandthejointsinbetween(typically,two
zygapophysealfacetjointsandoneintervertebraldisc).Generally,theaxisofmotionforeachunitis
inthenucleuspulposusoftheintervertebraldisc.Becausethespinecanmovefromtopdownor
bottomup,motionatafunctionalunitisdefinedbywhatisoccurringwiththeanteriorportionofthe
bodyofthesuperiorvertebra(Fig.14.3).
[Figure14.3.Motionsofthespinalcolumn.(A)Flexion/extension(forward/backwardbending).(B)
Lateralflexion(sidebending).(C)Rotation.(D)Anterior/posteriorshear.(E)Lateralshear.(F)
Distraction/compression.]
TheSixDegreesofMotion
Flexion/Extension.Motioninthesagittalplaneresultsinflexion(forwardbending)orextension
(backwardbending).Withflexion,theanteriorportionofthebodiesapproximateandthespinous
processesseparatewithextension,theanteriorportionofthebodiesseparateandthespinous
processesapproximate.
Sidebending.Motioninthefrontalplaneresultsinsidebending(lateralflexion)totheleftorright.
Withsidebending,thelateraledgesofthevertebralbodiesapproximateonthesidetowardwhich
thespineisbendingandseparatetheoppositeside.
Rotation.Motioninthetransverseplaneresultsinrotation.Rotationtotherightresultsinrelative
movementofthebodyofthesuperiorvertebraetotherightanditsspinousprocesstotheleftthe
oppositeoccurswithrotationtotheleft.Ifmovementoccursfromthepelvisupward,themotionis
stilldefinedbytherelativemotionofthetopvertebra.
Anterior/posteriorshear.Forwardorbackwardshear(translation)occurswhenthebodyofthe
superiorvertebratranslatesforwardorbackwardonthevertebrabelow.
Lateralshear.Lateralshear(translation)occurswhenthebodyofthesuperiorvertebratranslates
sidewaysonthevertebrabelow.
Compression/distraction.Separationorapproximationoccurswithalongitudinalforce,either
awayfromortowardthevertebralbodies.
Figure14.3.Motionsofthespinalcolumn.(A)Flexion/extension
(forward/backwardbending).(B)Lateralflexion(sidebending).(C)Rotation.(D)
Anterior/posteriorshear.(E)Lateralshear.(F)Distraction/compression.

ArthrokinematicsoftheZygapophyseal(Facet)Joints
Eachregionofthespinehasitsownspecialconsiderationsaspertainstoarthrokinematicmovement
andfunction.Thearthrokinematicsofthecraniovertebral(suboccipital)areaaredescribedbelow.
Theremainderofthecervicalspineandallthethoracicfacetshaverelativelyflatarticularsurfaces
andglideontheadjacentfacetjoint.14Thesuperiorfacetsofthelumbarspineareconcaveand
articulatewiththeadjacentinferiorconvexfacets.59ThearthrokinematicsaresummarizedinTable
14.1.
Coupledmotionstypicallyoccuratasegmentallevelwhenapersonsidebendsorrotatestheir
spine.Coupledmotionisdefinedas"consistentassociationofonemotionaboutanaxiswithanother
motionaroundadifferentaxis"14andvariesdependingontheregion,thespinalposture,the
orientationofthefacets,andfactorssuchasextensibilityofthesofttissues.Whenmotionsofside

bendingandrotationarecoupled,foraminalopeningisdictatedbythesidebendingcomponent.
Cervicalspine.Thecervicalspinecanbedividedintothesuboccipital(craniovertebral)regionand
the"typical"cervicalregion.
Thesuboccipitalregioniscomposedoftheocciput,atlas,andsuperiorfacetsoftheaxis.
Theoccipitalatlantal(OA)jointisconsideredaballandsocketjointtheconvexfacetsofthe
occiputarticulatewiththeconcavefacetsoftheatlas.Itsprimarymotionsareforwardand
backwardnodding(flexionandextension)(Fig.14.4).
Theatlantalaxial(AA)jointconsistsofconvexarticulatingsurfacesoftheatlasarticulatingonthe
convexarticulatingsurfacesoftheaxisitsprimarymotionisrotationastheatlaspivotsaround
thedensoftheaxis.Itisimportanttonotethat,duringrotation,onesideoftheAAjointcomplex
isbehavingasthoughitisflexing(movingforward)andtheothersideasthoughitisextending
(movingbackward)(Fig.14.5).ThereisasmallamountofsidebendingavailableattheOAjoint
rotationandsidebendingarecoupledinoppositedirectionsinthisregion.
Thetypicalcervicalregionincludestheinferiorfacetsoftheaxisandrestofthecervicalspineit
featuresfacetjointsthatareangledat45fromthehorizontalplane.Sidebendingandrotation
typicallycoupletowardthesameside.
AnotheruniquecharacteristicofthecervicalspineisthejointsofLuschka.Theseboneyprojections
providelateralstabilitytothespineandreinforcethevertebraldiscposterolaterally.
Thoracicspine.Thethoracicfacetsbegininafrontalplaneorientationandtransitiontoasagittal
planeorientationastheynearthelumbarspine.Theribsarticulatewiththethoracicspineatthe
transverseprocessesaswellasthevertebralbodiesandIVdiscs.Intheuprightposture,side
bendingandrotationtypicallycoupleinthesamedirectionintheupperthoracicspineandinthe
oppositedirectionsinthelowerthoracicregion,14althoughvariabilityhasbeendescribed.70
[Table14.1.ArthrokinematicsoftheSpine]
Lumbarspine.Asthelumbarfacetstransitionfromasagittalplanetoafrontalplaneorientation,
someofthefacetshaveabiplanarorientation.14Couplingvariesinthatwithlateralflexion,rotation
occurstothesameside,butwithrotation,lateralflexionoccursopposite14thereisvariabilitywith
flexionandextension.
Figure14.4.Noddingmotionsoftheatlantooccipitaljoints.(A)Flexion.(B)
Extension.
(FromLevangieandNorkin,14p.160withpermission.)

Figure14.5.Rotationoftheatlasaxisjoints(viewfromtheside).(A)Right
rotationshowingbackwardmovementoftherightarticulatingsurfaceofC1onC2.
(B)LeftrotationshowingforwardmovementoftherightarticulatingsurfaceofC1
onC2.

StructureandFunctionofIntervertebralDiscs
Theintervertebraldisc,consistingoftheannulusfibrosusandnucleuspulposus,isonecomponentof
athreejointcomplexbetweentwoadjacentvertebrae.Thestructureofthediscdictatesitsfunction
(Fig.14.6).14,45Annulusfibrosus.Theouterportionofthediscismadeupofdenselayersof
collagenfibersandfibrocartilage.Thecollagenfibersinanyonelayerareparallelandangledaround
60to65totheaxisofthespine,withthetiltalternatinginsuccessivelayers.26,42Becauseofthe
orientationofthefibers,tensilestrengthisprovidedtothediscbytheannuluswhenthespineis
distracted,rotated,orbent.Thisstructurehelpsrestrainthevariousspinalmotionsasacomplex
ligament.Theannulusisfirmlyattachedtoadjacentvertebrae,andthelayersarefirmlyboundto

oneanother.Fibersoftheinnermostlayersblendwiththematrixofthenucleuspulposus.The
annulusfibrosusissupportedbytheanteriorandposteriorlongitudinalligaments.
[Figure14.4.Noddingmotionsoftheatlantooccipitaljoints.(A)Flexion.(B)Extension.]
[Figure14.5.Rotationoftheatlasaxisjoints(viewfromtheside).(A)Rightrotationshowing
backwardmovementoftherightarticulatingsurfaceofC1onC2.(B)Leftrotationshowingforward
movementoftherightarticulatingsurfaceofC1onC2.]
Nucleuspulposus.Thecentralportionofthediscisagelatinousmassthatnormallyiscontained
within,butwhoselooselyalignedfibersmergewiththeinnerlayeroftheannulusfibrosus.Itis
locatedcentrallyinthediscexceptinthelumbarspine,whereitissituatedclosertothe
[Figure14.6.Intervertebraldisc.(A)Theannularringsenclosethenucleuspulposus,providinga
mechanismfordissipatingcompressiveforces.(B)Orientationofthelayersoftheannulusprovides
tensilestrengthtothediscwithmotionsinvariousdirections.]
posteriorborderthantheanteriorborderoftheannulus.Aggregatingproteoglycans,normallyinhigh
concentrationinahealthynucleus,havegreataffinityforwater.Theresultingfluidmechanicsofthe
confinednucleusfunctionstodistributepressureevenlythroughoutthediscandfromonevertebral
bodytothenextunderloadedconditions.Becauseoftheaffinityforwater,thenucleusimbibes
waterwhenpressureisreducedonthediscandsqueezeswateroutundercompressiveloads.These
fluiddynamicsprovidetransportfornutrientsandhelpmaintaintissuehealthinthedisc.
Withflexion(forwardbending)ofavertebralsegment,theanteriorportionofthediscis
compressed,andtheposteriorisdistracted.Thenucleuspulposusgenerallydoesnotmoveina
healthydiscbutmayhaveslightdistortionwithflexion,potentiallytoredistributetheloadthrough
thedisc.43Asymmetricalloadinginflexionresultsindistortionsofthenucleustowardthe
contralateralposterolateralcorner,wherethefibersoftheannulusaremorestretched.
Cartilaginousendplates.Endplatescoverthenucleuspulposussuperiorlyandinferiorlyandlie
betweenthenucleusandvertebralbodies.Eachisencircledbytheapophysealringoftherespective
vertebralbody.14Thecollagenfibersoftheinnerannulusfibrosusinsertintotheendplateandangle
centrally,thusencapsulatingthenucleuspulposus.Nutritiondiffusesfromthemarrowofthe
vertebralbodiestothediscviatheendplates.14Theendplatesarealsoresponsibleforcontaining
thenucleusfrommigratingsuperior/inferior.
Figure14.6.Intervertebraldisc.(A)Theannularringsenclosethenucleus
pulposus,providingamechanismfordissipatingcompressiveforces.(B)Orientation
ofthelayersoftheannulusprovidestensilestrengthtothediscwithmotionsin
variousdirections.

IntervertebralForamina
Theintervertebralforaminaarebetweeneachvertebralsegmentintheposteriorpillar.Theiranterior
boundaryistheintervertebraldisctheposteriorboundaryisthefacetjointandthesuperiorand
inferiorboundariesarethepediclesofthesuperiorandinferiorvertebraeofthespinalsegment.The
mixedspinalnerveexitsthespinalcanalviatheforamenalongwithbloodvesselsandrecurrent
meningealorsinuvertebralnerves.Thesizeoftheintervertebralforaminaisaffectedbyspinal
motion,beinglargerwithforwardbendingandcontralateralsidebendingandsmallerwithextension
andipsilateralsidebending.

BiomechanicalInfluencesonPosturalAlignment
CurvesoftheSpine
Theadultspineisdividedintofourcurves:twoprimary,orposterior,curves,sonamedbecausethey
arepresentintheinfantandtheconvexityisposteriorandtwocompensatory,oranterior,curves,
sonamedbecausetheydevelopastheinfantlearnstolifttheheadandeventuallystand,andthe
convexityisanterior.

Posteriorcurvesareinthethoracicandsacralregions.Kyphosisisatermusedtodenoteaposterior
curve.Kyphoticposturereferstoanexcessiveposteriorcurvatureofthethoracicspine.41
Anteriorcurvesareinthecervicalandlumbarregions.Lordosisisatermalsousedtodenotean
anteriorcurve,althoughsomesourcesreservethetermlordosistodenoteabnormalconditionssuch
asthosethatoccurwithaswayback.41
Thecurvesandflexibilityinthespinalcolumnareimportantforwithstandingtheeffectsofgravity
andotherexternalforces.14,51
Thestructureofthebones,joints,muscles,andinerttissuesofthelowerextremitiesaredesigned
forweightbearingtheysupportandbalancethetrunkintheuprightposture.Lowerextremity
alignmentandfunctionaredescribedingreaterdetailineachoftheextremitychapters(see
Chapters20to22).

Gravity
Whenlookingatpostureandfunction,itiscriticaltounderstandtheinfluenceofgravityonthe
structuresofthetrunkandlowerextremities.Gravityplacesstressonthestructuresresponsiblefor
maintainingthebodyuprightandtherefore,providesacontinualchallengetostabilityandefficient
movement.Foraweightbearingjointtobestable,orinequilibrium,thegravitylineofthemass
mustfallexactlythroughtheaxisofrotation,ortheremustbeaforcetocounteractthemoment
causedbygravity.44Inthebody,thecounterforceisprovidedbyeithermuscleorinertstructures.In
addition,thestandingpostureusuallyinvolvesaslightanterior/posteriorswayingofthebodyof
about4cm.,somusclesarenecessarytocontroltheswayandmaintainequilibrium.
Intheuprightposture,thelineofgravitytransectsthespinalcurves,whicharebalancedanteriorly
andposteriorly,anditisclosetotheaxisofrotationinthelowerextremityjoints.Thefollowing
describesthestandardofabalanceduprightposture(Fig.14.7).Ankle.Fortheankle,thegravity
lineisanteriortothejoint,soittendstorotatethetibiaforwardabouttheankle.Stabilityis
providedbytheplantarflexormuscles,primarilythesoleusmuscle.
Knee.Thenormalgravitylineisanteriortothekneejoint,whichtendstokeepthekneein
extension.Stabilityisprovidedbytheanteriorcruciateligament,posteriorcapsule(locking
mechanismoftheknee),andtensioninthemusclesposteriortotheknee(thegastrocnemiusand
hamstringmuscles).Thesoleusprovidesactivestabilitybypullingposteriorlyonthetibia.Withthe
kneesfullyextended,nomusclesupportisrequiredatthatjointtomaintainanupright
[Figure14.7.Lateralviewofstandardposturalalignment.Aplumblineistypicallyusedfor
referenceandrepresentstherelationshipofthebodypartswiththelineofgravity.Surface
landmarksareslightlyanteriortothelateralmalleolus,slightlyanteriortotheaxisofthekneejoint,
throughthegreatertrochanter(slightlyposteriortotheaxisofthehipjoint),throughthebodiesof
thelumbarandcervicalvertebrae,throughtheshoulderjoint,andthroughthelobeoftheear.]
posturehowever,ifthekneesflexslightly,thegravitylineshiftsposteriortothejoint,andthe
quadricepsfemorismusclemustcontracttopreventthekneefrombuckling.
Hip.Thegravitylineatthehipvarieswiththeswayingofthebody.Whenthelinepassesthrough
thehipjoint,thereisequilibrium,andnoexternalsupportisnecessary.Whenthegravitationalline
shiftsposteriortothejoint,someposteriorrotationofthepelvisoccurs,butiscontrolledbytension
inthehipflexormuscles(primarilytheiliopsoas).Duringrelaxedstanding,theiliofemoralligament
providespassivestabilitytothejoint,andnomuscletensionisnecessary.Whenthegravitational
lineshiftsanteriorly,stabilityisprovidedbyactivesupportofthehipextensormuscles.
Trunk.Normally,thegravitylineinthetrunkgoesthroughthebodiesofthelumbarandcervical
vertebrae,andthecurvesarebalanced.Someactivityinthemusclesofthetrunkandpelvishelps
maintainthebalance.(Thisisdescribedingreaterdetailinthefollowingsections.)Asthetrunk
shifts,contralateralmusclescontractandfunctionasguywires.Extremeorsustaineddeviationsare
supportedbyinertstructures.
Head.Thecenterofgravityoftheheadfallsanteriortotheatlantooccipitaljoints.Theposterior

cervicalmusclescontracttokeeptheheadbalanced.
Figure14.7.Lateralviewofstandardposturalalignment.Aplumblineistypically
usedforreferenceandrepresentstherelationshipofthebodypartswiththelineof
gravity.Surfacelandmarksareslightlyanteriortothelateralmalleolus,slightly
anteriortotheaxisofthekneejoint,throughthegreatertrochanter(slightly
posteriortotheaxisofthehipjoint),throughthebodiesofthelumbarandcervical
vertebrae,throughtheshoulderjoint,andthroughthelobeoftheear.

Stability
Introduction
Solongasthelineofgravityfromthecenterofmassfallswithinthebaseofsupport,astructureis
stable.Stabilityisimprovedbyloweringthecenterofgravityorincreasingthebaseofsupport.In
theuprightposition,thebodyisrelativelyunstable,becauseitisatallstructurewithasmallbaseof
support.Whenthecenterofgravityfallsoutsidethebaseofsupport,eitherthestructurefallsor
someforcemustacttokeepthestructureupright.Bothinertanddynamicstructuressupportthe
bodyagainstgravitationalandotherexternalforces.Theinertosseousandligamentousstructures
providepassivetensionwhenajointreachestheendofitsrangeofmotion(ROM).Musclesactas
dynamicguywires,respondingtoperturbationsbyprovidingcounterforcestothetorqueofgravity
aswellasstabilitywithintheROMsostressesarenotplacedontheinerttissues.

PosturalStabilityintheSpine
Spinalstabilityisdescribedintermsofthreesubsystems:passive(inertstructures/bonesand
ligaments),active(muscles),andneuralcontrol.19,58Thethreesubsystemsareinterrelatedandcan
bethoughtofasathreeleggedstoolifanyoneofthelegsisnotprovidingsupport,itaffectsthe
stabilityofthewholestructure.58Instabilityofaspinalsegmentisoftenacombinationofinert
tissuedamage,insufficientmuscularstrengthorendurance,andpoorneuromuscularcontrol.3,19

InertStructures:InfluenceonStability
Penjabi57,58describedtheROMofanyonesegmentasbeingdividedintoanelasticzoneanda
neutralzone.Whenspinalsegmentsareintheneutralzone(midrange/neutralrange),theinertjoint
capsulesandligamentsprovideminimalpassiveresistancetomotionandtherefore,minimal
stability.Asasegmentmovesintotheelasticzone,theinertstructuresproviderestraintaspassive
resistancetothemotionoccurs.Whenastructurelimitsmovementinaspecificdirection,itprovides
stabilityinthatdirection.Inadditiontotheinerttissuesprovidingpassivestabilitywhenlimiting
motion,thesensoryreceptorsinthejointcapsulesandligamentssensepositionandchangesin
position.Stimulationofthesereceptorsprovidesfeedbacktothecentralnervoussystem,thus
influencingtheneuralcontrolsystem.58,60Table14.2summarizesthestabilizingfeaturesofthe
osteoligamentoustissuesinthespine.
[Table14.2.StabilizingFeaturesofInertTissuesintheSpine]

Muscles:InfluenceonStability
RoleofGlobalandSegmentalMuscleActivity
Themusclesofthetrunknotonlyactasprimemoversorasantagoniststomovementcausedby
gravityduringdynamicactivity,theyareimportantstabilizersofthespine.3,8,9,22,34,49,60Without
thedynamicstabilizingactivityfromthetrunkmuscles,thespinewouldcollapseintheupright
position.12Bothsuperficial(global)anddeep(segmental)musclesplaycriticalrolesinproviding
stabilityandmaintainingtheuprightposture.Table14.3summarizesthestabilizingcharacteristicsof
thesetwomusclegroups.
Globalmusclefunction.Inthelumbarspine,theglobalmuscles,beingthemoresuperficialofthe
twogroups,arethelargeguywiresthatrespondtoexternalloadsimposedonthetrunkthatshift
thecenterofmass(Fig.14.8A).Theirreactionisdirectionspecifictocontrolspinalorientation.3,34

Theglobalmusclesareunabletostabilizeindividualspinalsegmentsexceptthroughcompressive
loading,becausetheyhavelittleornodirectattachmenttothevertebrae.Ifanindividualsegmentis
unstable,compressiveloadingfromtheglobalguywiresmayleadtoorperpetuateapainful
situationasstressisplacedontheinerttissuesattheendoftherangeofthatsegment(Fig.14.8
B).
[Figure14.8.(A)Guywirefunctionofglobaltrunkmusclesprovidesoverallstabilityagainst
perturbations.(B)Instabilityinthemultisegmentalspinecannotbecontrolledbytheglobaltrunk
muscleguywires.Compressiveloadingfromthelongguywiresleadstostressontheinerttissues
attheendrangesoftheunstablesegment.]
Deep/segmentalmusclefunction.Thedeeper,segmentalmuscles,whichhavedirectattachments
acrossthevertebralsegments,providedynamicsupporttoindividualsegmentsinthespineandhelp
maintaineachsegmentinastableposition,sotheinerttissuesarenotstressedatthelimitsof
motion(Fig.14.9).34,38,39,50
[Figure14.9.Deepmusclesattachedtoeachspinalsegmentprovidesegmentalstability.]
[Table14.3.StabilizingFeaturesofMusclesControllingtheSpine]
MuscleControlintheLumbarSpine
GeneralmusclefunctionandstabilizingactionsofthemusclesofthespinearesummarizedinTable
14.4.
[Table14.4.MusclesoftheSpineandTheirStabilizingFunction]
Abdominalmuscles(Fig.14.10).Therectusabdominis(RA),externaloblique(EO),andinternal
oblique(IO)musclesarelarge,multisegmentalglobalmusclesandareimportantguywiresfor
stabilizingthespineagainstposturalperturbations.Thetransversusabdominis(TrA)isthedeepestof
theabdominalmusclesandrespondsuniquelytoposturalperturbations.Itattachesposteriorlytothe
lumbarvertebraeviatheposteriorandmiddlelayersofthethoracolumbarfascia(Figs.14.11and
14.12)andthroughitsactiondevelopstensionthatactslikeagirdleofsupportaroundtheabdomen
andlumbarvertebrae.OnlytheTrAisactivewithbothisometrictrunkflexionandextension,
whereastheotherabdominalmuscleshavedecreasedactivitywithresistedextension.Thisis
attributedtothestabilizationfunctionoftheTrA.11,36
Transversusabdominisstabilizationactivity.Earlyelectromyographicresearchstudiesofthe
activityofthedeeperabdominalmusclesintheirstabilizationfunctionweredonewithsurface
electrodesanddidnotdiscriminateactivitybetweentheTrAandIO.Byusingultrasoundimaging
techniques,
[Figure14.10.Abdominalmuscles.]
[Figure14.11.Transversesectioninthelumbarregionshowstherelationshipsofthethreelayers
ofthethoracolumbarfasciatothemusclesintheregionandtheirattachmentstothespine.(ES,
erectorspinaeMf,multifidusTA,transversusabdominisIO,internalobliquesEO,external
obliquesLD,latissimusdorsiPM,psoasmajorQL,quadratuslumborummuscles.)]
insertionoffineneedleelectrodesintothevariousmuscleshasproducedevidenceofdiffering
functionsbetweenthesetwomuscleswithperturbationstobalanceinhealthyindividualsaswellas
thosewhohavelowbackpathology.32
TheTrArespondswithanticipatoryactivityandwithrapidarmandlegmovements(beforetheother
abdominals)andcoordinateswithrespirationduringtheseactivities.34,38,39TheTrAalsohasa
coordinatedlinkwiththeperineumandpelvicfloormusclefunction(seeChapter24),6,13,52,63,64as
wellaswiththedeepfibersofthemultifidi.34,3739,50The"drawingin"maneuverisusedtoactivate
theTrAvoluntarilyand,withtraining,producesthemostindependentactivityofthismuscle.61,68
(SeeChapter16foradescriptionofthismaneuver.)Erectorspinaemuscles(Fig.14.13).The
erectorspinaemusclesarethelong,multisegmentalextensorsthatbeginasalarge
musculotendinousmassoverthesacralandlowerlumbarvertebrae.Theyareimportantglobalguy
wiresforcontrollingthetrunkagainstposturalperturbations.

Multifidusstabilizationactivity.Themultifasciculedmultifidimusclegrouphasahighdistribution
oftypeIfibersandlargecapillarynetwork,emphasizingitsroleasatonicstabilizer.Itssegmental
attachmentsareabletocontrolmovementofthespinalsegmentsaswellasincreasespinal
stiffness.The
[Figure14.12.Orientationandattachmentsoftheposteriorlayerofthethoracolumbarfascia.From
thelateralraphe,(A)thefibersofthesuperficiallaminaareangledinferiorlyandmediallyand(B)
thefibersofthedeeplaminaareangledsuperiorlyandmedially.(C)Tensionintheangledfibersof
theposteriorlayerofthefasciaistransmittedtothespinousprocessesinopposingdirections,
resistingseparationofthespinousprocesses.(D)Diagrammaticrepresentationofalateralpullat
thelateralraphe,resultingintensionbetweenthelumbarspinousprocessesthatopposeseparation,
thusprovidingstabilitytothespine.]
[Figure14.13.Musclesoftheback.]
multifidus,alongwiththeerectorspinae,areencasedbytheposteriorandmiddlelayersofthe
lumbodorsalfascia(seeFig.14.11),sobulkandmusclecontractionincreasetensiononthefascia,
addingtothestabilizingfunctionofthefascia(seebelowforadescriptionofthismechanism).

FocusonEvidence
IthasbeenshownthatactivationandfunctionintheTrAchange(delayedandmorephasic)in
patientswithlowbackpain,possiblyindicatinglesseffectivestabilizingaction32,35andthattraining
theTrAforposturalcontrolandstabilityimprovesthelongtermoutcome.27
Inpatientswithlowbackimpairment,thefibersofthemultifidiquicklyatrophyatthespinal
segment,28andamotheatenappearancehasbeenreportedinpatientsundergoingsurgeryfor
lumbardiscdisease.60Evidencesupportstheideathattrainingwithspecificexercisesincreasesthe
functionofthemultifidiaswellastheerectorspinaeingeneral.15,27,29Otherdeepmusclesthat
theoreticallyplayaroleinsegmentalstabilitybuttothispointintimehavebeendifficulttoassess
becauseoftheirdepthincludetheintersegmentalmuscles(rotatorsandintertransversariimuscles)
anddeepfibersofthequadratuslumborum.
Thoracolumbar(lumbodorsal)fascia.Thethoracolumbarfasciaisanextensivefascialsystemin
thebackthatconsistsofseverallayers.7,8,2224Itsurroundstheerectorspinae,multifidi,and
quadratuslumborum,thusprovidingsupporttothesemuscleswhentheycontract23(seeFig.14.11).
Increasedbulkinthesemusclesincreasestensioninthefascia,perhapscontributingthestabilizing
functionofthesemuscles.
Theaponeurosisofthelatissimusdorsiandfibersfromtheserratusposteriorinferior,internal
oblique,andtransverseabdominismusclesblendtogetheratthelateralrapheofthethoracolumbar
fascia,socontractioninthesemusclesincreasestensionthroughtheangledfascia,providing
stabilizingforcesforthelumbarspine23(seeFig.14.12).Inaddition,the"X"designofthelatissimus
dorsiandcontralateralgluteusmaximushasthepotentialtoprovidestabilitytothelumbosacral
junction.
MuscleControlintheCervicalSpine
Thefulcrumoftheheadonthespineisthroughtheoccipital/atlasjoints.Thecenterofgravityofthe
headisanteriortothejointaxisandthereforehasaflexionmoment.Theweightoftheheadis
counterbalancedbythecervicalextensormuscles(uppertrapeziusandcervicalerectorspinae).
Tensionandfatigueinthesemuscles,aswellasinthelevatorscapulae(whichsupportstheposture
ofthescapulae),isexperiencedbymostpeoplewhoexperienceposturalstresstotheheadandneck
(Fig.14.14).Thepositionofthemandibleandthetensioninthemusclesofmasticationare
influencedbytheposturalrelationshipbetweenthecervicalspineandhead.
Mandibularelevatorgroup.Themandibleisamovablestructurethatismaintainedinitsresting
positionwiththejawpartiallyclosedthroughactionofthemandibularelevators(masseter,
temporalis,andinternalpterygoidmuscles).

[Figure14.14.Headbalanceonthecervicalspine.Theposteriorcervicalmuscles(trapeziusand
semispinaliscapitis)countertheweightofthehead.Themandibularelevatingmuscles(masseter,
temporalis,medialpterygoid)maintainjawelevationopposingthemandibulardepressionforceof
gravityandtensionintheanteriorthroatmuscles(suprahyoidandinfrahyoidgroups).Thescalene
andlevatormusclesstabilizeagainsttheposteriorandanteriortranslatoryforcesonthecervical
vertebrae.(Tr,trapeziusSC,semispinaliscapitisM,masseterT,temporalisMT,medialpterygoid
SH,suprahyoidIH,infrahyoidS,scaleneLS,levatorscapulaeG,centerofgravity ,axisof
motion.)]
Suprahyoidandinfrahyoidgroup.Theanteriorthroatmusclesassistwithswallowingand
balancingthejawagainstthemusclesofmastication.Thesemusclesalsofunctiontoflextheneck
whenrisingfromthesupineposition.Withaforwardheadposture,they,alongwiththelonguscolli,
tendtobestretchedandweaksothepersonliftstheheadwiththesternocleidomastoid(SCM)
muscles.
Rectuscapitisanteriorandlateralis,longuscolli,andlonguscapitis(Fig.14.15).Thedeep
craniocervicalflexormuscleshavesegmentalattachmentsandprovidedynamicsupporttothe
cervicalspineandhead.25Thelonguscolliisimportantintheactionofaxialextension(retraction)
andworkswiththeSCMforcervicalflexion.Withoutthesegmentalinfluenceofthelonguscolli,the
SCMwouldcauseincreasedcervicallordosiswhenattemptingflexion.5
[Figure14.15.Deepsegmentalmusculatureinthecervicalspine:rectuscapitisanteriorand
lateralis,longuscolli,longuscapitis,andscalenemuscles.]
Multifidus.Withitssegmentalattachments,themultifidusisthoughttohavealocalstabilizing
functioninthecervicalspinesimilartoitsfunctioninthelumbarregion(seeFig.14.13).25
RoleofMuscleEndurance
Strengthiscriticalforcontrollinglargeloadsorrespondingtolargeandunpredictableloads(suchas
duringheavylabor,sports,orfalls),butonlyabout10%ofmaximumcontractionisneededto
providestabilityinusualsituations.3Slightlymoremightbeneededinasegmentdamagedbydisc
diseaseorligamentouslaxitywhenmusclesarecalledontocompensateforthedeficitinthepassive
support.3
GreaterpercentagesoftypeIfibersthantypeIIfibersarefoundinallbackmuscles,whichis
reflectiveoftheirposturalandstabilizationfunctions.53Inactivityhasbeenshowntochangemuscle
fibercomposition,leadingtodecreasedmuscularenduranceduringsustainedorrepetitiveactivities
andmaybeonereasonfordecreasedfunctioninpatientswithlowbackpain.53

FocusonEvidence
Inastudythatlookedat17mechanicalfactorsandtheoccurrenceoflowbackpainin600subjects
(ages20through65),poormuscularenduranceinthebackextensorsmuscleshadthegreatest
associationwithlowbackpain.54

Figure14.8.(A)Guywirefunctionofglobaltrunkmusclesprovidesoverall
stabilityagainstperturbations.(B)Instabilityinthemultisegmentalspinecannotbe
controlledbytheglobaltrunkmuscleguywires.Compressiveloadingfromthelong
guywiresleadstostressontheinerttissuesattheendrangesoftheunstable
segment.
Figure14.9.Deepmusclesattachedtoeachspinalsegmentprovidesegmental
stability.

Figure14.10.Abdominalmuscles.

Figure14.11.Transversesectioninthelumbarregionshowstherelationshipsof
thethreelayersofthethoracolumbarfasciatothemusclesintheregionandtheir
attachmentstothespine.(ES,erectorspinaeMf,multifidusTA,transversus
abdominisIO,internalobliquesEO,externalobliquesLD,latissimusdorsiPM,
psoasmajorQL,quadratuslumborummuscles.)
Figure14.12.Orientationandattachmentsoftheposteriorlayerofthe
thoracolumbarfascia.Fromthelateralraphe,(A)thefibersofthesuperficiallamina
areangledinferiorlyandmediallyand(B)thefibersofthedeeplaminaareangled
superiorlyandmedially.(C)Tensionintheangledfibersoftheposteriorlayerofthe
fasciaistransmittedtothespinousprocessesinopposingdirections,resisting
separationofthespinousprocesses.(D)Diagrammaticrepresentationofalateral
pullatthelateralraphe,resultingintensionbetweenthelumbarspinousprocesses
thatopposeseparation,thusprovidingstabilitytothespine.
(AC.AdaptedfromBogduckandMacIntosh,7pp.166167,169,withpermission.D.
AdaptedfromGracovetskyetal.,22p.319,withpermission.)
Figure14.13.Musclesoftheback.

Figure14.14.Headbalanceonthecervicalspine.Theposteriorcervicalmuscles
(trapeziusandsemispinaliscapitis)countertheweightofthehead.Themandibular
elevatingmuscles(masseter,temporalis,medialpterygoid)maintainjawelevation
opposingthemandibulardepressionforceofgravityandtensionintheanterior
throatmuscles(suprahyoidandinfrahyoidgroups).Thescaleneandlevatormuscles
stabilizeagainsttheposteriorandanteriortranslatoryforcesonthecervical
vertebrae.(Tr,trapeziusSC,semispinaliscapitisM,masseterT,temporalisMT,
medialpterygoidSH,suprahyoidIH,infrahyoidS,scaleneLS,levatorscapulae
G,centerofgravity ,axisofmotion.)
Figure14.15.Deepsegmentalmusculatureinthecervicalspine:rectuscapitis
anteriorandlateralis,longuscolli,longuscapitis,andscalenemuscles.

NeurologicalControl:InfluenceonStability
Themusclesoftheneckandtrunkareactivatedandcontrolledbythenervoussystem,whichis
influencedbyperipheralandcentralmechanismsinresponsetofluctuatingforcesandactivities.
Basically,thenervoussystemcoordinatestheresponseofmusclestoexpectedandunexpected

forcesattherighttimeandbytherightamountbymodulatingstiffnessandmovementtomatchthe
variousimposedforces.3,16,34

Feedforwardcontrolandspinalstability.Thecentralnervoussystemactivatesthetrunk
musclesinanticipationoftheloadimposedbylimbmovementtomaintainstabilityinthespine.39
Researchhasdemonstratedthattherearefeedforwardmechanismsthatactivateposturalresponses
ofalltrunkmusclesprecedingactivityinmusclesthatmovetheextremities34,37,39andthat
anticipatoryactivationofthetransversusabdominisanddeepfibersofthemultifidusisindependent
ofthedirectionorspeedoftheposturaldisturbance.32,33,38,50Themoresuperficialtrunkmuscles
varyinresponsedependingonthedirectionofarmandlegmovement,reflectiveoftheirpostural
guywirefunction,whichcontrolsdisplacementofthecenterofmasswhenthebodychanges
configuration.34,39Therearereporteddifferencesinpatternsofmusclerecruitmentinpatientswith
lowbackpainwithdelayedrecruitmentofthetransversusabdominisinallmovementdirectionsand
delayedrecruitmentoftherectusabdominis,erectorspinae,andobliqueabdominalmusclesspecific
tothedirectionofmovementcomparedtohealthysubjects.35

FocusonEvidence
AstudybyAllisonandassociates1collecteddatafrommuscleactivityoftheTrA,internalobliques,
erectorspinae,andmultifidusmusclegroupsbilaterallyinsevensubjectsandprovidedevidencethat
challengestheconceptofbilateralfeedforwardsymmetryintheactivationoftheTrA,andthatalso
contradictspreviouslypublishedstudiesthatcontractionoftheTrAisindependentofthedirectionof
armmovementcausingtrunkperturbations.Thedatasupportsthemotorcontrolstrategyoffeed
forwardactivity,butchallengestheinfluenceofsupporttothespinethroughsymmetricalforce
generationduetotheasymmetryinactivationpatternsdependentonsideanddirectionofarm
movementandthusdirectiontrunkperturbations.TheauthorsacknowledgethevalueofTrAtraining
butsuggestfurtherresearchisneededtoprovideexplanationforthemechanismofitsstabilizing
action.

EffectsofLimbFunctiononSpinalStability
Withoutadequatestabilizationofthespine,contractionofthelimbgirdlemusculaturetransmits
forcesproximallyandcausesmotionsofthespinethatplaceexcessivestressesonspinalstructures
andthesupportingsofttissue.
Localizedmusclefatigue.Localizedfatigueinthestabilizingspinalmusculaturemayoccurwith
repetitiveactivityorheavyexertionorwhenthemusculatureisnotutilizedeffectivelyduetofaulty
postures.Thereisagreaterchanceofinjuryinthesupportingstructuresofthespinewhenthe
stabilizingmusclesfatigue.MarrasandGranata47reportedsignificantchangesinmotionpatterns
betweenthespineandlowerextremityjointsaswellassignificantchangesinmusclerecruitment
patternswithrepetitiveliftingduringanextendedperiodoftime,resultinginincreased
anterior/posteriorshearinthelumbarspine.
Muscleimbalances.Imbalancesintheflexibilityandstrengthofthehip,shoulder,andneck
musculaturecauseasymmetricalforcesonthespineandaffectposture.Commonproblemsare
describedinthesectionlaterinthischapteron"CommonFaultyPostures."

ClinicalTip
Stabilizationofthepelvisandlumbarspinebytheabdominalmusclesagainstthepulloftheiliopsoas
muscleisnecessaryduringactivehipflexiontoavoidincreasedlumbarlordosisandanterior
shearingofthevertebrae.
Stabilizationoftheribsbytheintercostalandabdominalmusclesisnecessaryforaneffective
pushingforcefromthepectoralismajorandserratusanteriormuscles.
Stabilizationofthecervicalspinebythelonguscollimuscleisnecessarytopreventexcessive
lordosisfromcontractionoftheuppertrapeziusasitfunctionswiththeshouldergirdlemusclesin

liftingandpullingactivities.

EffectsofBreathingonPostureandStability
Inspirationandthoracicspineextensionelevatetheribcageandassistwithposture.Theintercostal
musclesfunctionasposturalmusclestostabilizeandmovetheribs.Theyactasadynamic
membranebetweentheribstopreventsuckinginandblowingoutofthesofttissuewiththe
pressurechangesduringrespiration.4ThestabilizingfunctionoftheTrAalsoworksinconjunction
withthediaphragminafeedforwardresponsetorapidarmmotions.Contractionofthediaphragm
andincreasedintraabdominalpressureoccurpriortorapidarmmovement,irrespectiveofthe
phaseofrespirationorthedirectionofthearmmotion.34,36ThetonicactivitiesoftheTrAand
diaphragmaremodulatedtomeetrespiratorydemandsduringbothinspirationandexpirationand
providestabilitytothespinewhentherearerepetitivelimbmovements.30,31

EffectsofIntraabdominalPressureandtheValsalvaManeuveronStability
DuringtheValsalvamaneuver,contractionoftheTrA,IO,andEOmusclesincreaseintraabdominal
pressure(IAP).11ContractionoftheTrAalonepushestheabdominalcontentsupagainstthe
diaphragmtherefore,tocompletetheenclosedchamber,thediaphragmandpelvicfloormuscles
contractinsynchronywiththeTrA.52ThereareseveralideasthatexplainhowIAPimprovesspinal
stability.Theincreasedpressureintheenclosedchambermayacttounloadthecompressiveforces
onthespineaswellasincreasethestabilizingeffectbypushingoutagainsttheabdominalmuscles,
increasingtheirlengthtensionrelationshipandtensiononthethoracolumbarfascia(Figs.14.16and
14.17).63ItisalsosuggestedthattheIAPmayacttopreventbucklingofthespineandthusprevent
tissuestrainorfailure.10
TheValsalvamaneuverisatechniquefrequentlyusedbyindividualsliftingheavyloadsand
potentiallyhascardiovascularrisks(seeChapter6),soitisrecommendedthatindividualsbe
[Figure14.16.Coordinatedcontractionofthetransversusabdominis,diaphragm,andpelvicfloor
musculatureincreasesintraabdominalpressure,whichunloadsthespineandprovidesstability.]
[Figure14.17.(A)Increasedintraabdominalpressure(IAP)pushesoutwardagainstthe
transversusabdominisandinternalobliques,creatingincreasedtensiononthethoracolumbarfascia,
resultinginimprovedspinalstability.(B)Reducedpressuredecreasesthestabilizingeffect.]
taughttoexhalewhilemaintainingtheabdominalcontractionstodecreasetherisks.Inaddition,
Hodgesandassociates36foundthatifastaticexpulsiveeffortismaintained(holdingthebreathwhile
contractingtheabdominalmuscles),activationofthetransverseabdominisisdelayed.Because
activationofthetransversusabdominisisnecessaryforsegmentalspinalstability,expirationduring
exertionreinforcesthisstabilizingfunction.
Figure14.16.Coordinatedcontractionofthetransversusabdominis,diaphragm,
andpelvicfloormusculatureincreasesintraabdominalpressure,whichunloadsthe
spineandprovidesstability.

Figure14.17.(A)Increasedintraabdominalpressure(IAP)pushesoutward
againstthetransversusabdominisandinternalobliques,creatingincreasedtension
onthethoracolumbarfascia,resultinginimprovedspinalstability.(B)Reduced
pressuredecreasesthestabilizingeffect.
(AdaptedfromGracovetsky,24p.114,withpermission.)

ImpairedPosture

Introduction
Inordertomakesoundclinicaldecisionswhenmanagingpatientswithactivityorparticipation
restrictions(functionallimitations)duetospinalimpairments,itisnecessarytounderstandthe
underlyingeffectsoffaultypostureonflexibility,strength,andthepainexperiencedbythe
individual.Impairedposturemaybetheunderlyingcauseofthepatient'spainormaybetheresult
ofsometraumaticorpathologicalevent.Inthissection,theetiologyofpainandcommonfaulty
posturesaredescribedindetailfollowedbyguidelinesfordevelopingtherapeuticexercise
interventions.ImpairedpostureisclassifiedinTheGuidetoPhysicalTherapistPractice,second
edition,under"MusculoskeletalDiagnosticClassificationPatternB:ImpairedPosture."1a

EtiologyofPain
EffectofMechanicalStress
Theligaments,facetcapsules,periosteumofthevertebrae,muscles,anteriorduramater,dural
sleeves,epiduralareolaradiposetissue,andwallsofbloodvesselsareinnervatedandresponsiveto
nociceptivestimuli.14Mechanicalstresstopainsensitivestructures,suchassustainedstretchto
ligamentsorjointcapsulesorcompressionofbloodvessels,causesdistentionorcompressionofthe
nerveendings,whichleadstotheexperienceofpain.Thistypeofstimulusoccursintheabsenceof
aninflammatoryreaction.Itisnotapathologicalproblembutamechanicalonebecausesignsof
acuteinflammationwithconstantpainarenotpresent.
Relievingthestresstothepainsensitivestructurerelievesthepainstimulus,andthepersonno
longerexperiencespain.Ifthemechanicalstressesexceedthesupportingcapabilitiesofthetissues,
breakdownensues.Ifitoccurswithoutadequatehealing,musculoskeletaldisordersoroveruse
syndromeswithinflammationandpainaffectfunctionwithoutanapparentinjury(seeChapter10).
Relievingthemechanicalstress(i.e.,correctingtheposture)alongwithdecreasingtheinflammation
isimportant.

EffectofImpairedPosturalSupportfromTrunkMuscles
Littlemuscleactivityisrequiredtomaintainuprightposturebutwithtotalrelaxationofmuscles,the
spinalcurvesbecomeexaggerated,andpassivestructuralsupportiscalledontomaintainthe
posture.Whenthereiscontinuedendrangeloading,strainoccurswithcreepandfluidredistribution
inthesupportingtissues,makingthemvulnerabletoinjury.66
Continualexaggerationofthecurvesleadstoposturalimpairmentandmusclestrengthandflexibility
imbalancesaswellasothersofttissuerestrictionsorhypermobility.Musclesthatarehabituallykept
inastretchedpositiontendtotestweakerbecauseofashiftinthelengthtensioncurvethisis
knownasstretchweakness.41Muscleskeptinahabituallyshortenedpositiontendtolosetheir
elasticity.Thesemusclesteststrongonlyintheshortenedpositionbutbecomeweakastheyare
lengthened.21Thisconditionisknownastightweakness.21

EffectofImpairedMuscleEndurance
Enduranceinmusclesisnecessarytomaintainposturalcontrol.Sustainedposturesrequirecontinual,
smalladaptationsinthestabilizingmusclestosupportthetrunkagainstfluctuatingforces.Large,
repetitivemotionsalsorequiremusclestorespondsoastocontroltheactivity.Ineithercase,asthe
musclesfatigue,themechanicsofperformancechangeandtheloadisshiftedtotheinerttissues
supportingthespineattheendranges.65Withpoormuscularsupportandasustainedloadonthe
inertsupportingtissues,creepanddistentionoccur,causingmechanicalstress.Inaddition,injuries
occurmorefrequentlyafteralotofrepetitiveactivityorlongperiodsofworkandplaywhenthereis
musclefatigue.

PainSyndromesRelatedtoImpairedPosture
Posturalfault.Aposturalfaultisaposturethatdeviatesfromnormalalignmentbuthasno
structuralimpairments.
Posturalpainsyndrome.Posturalpainsyndromereferstothepainthatresultsfrommechanical
stresswhenapersonmaintainsafaultypostureforaprolongedperiodthepainisusuallyrelieved

withactivity.Therearenoimpairmentsinfunctionalstrengthorflexibility,butifthefaultyposture
continues,strengthandflexibilityimbalanceseventuallydevelop.
Posturaldysfunction.Posturaldysfunctiondiffersfromposturalpainsyndromeinthatadaptive
shorteningofsofttissuesandmuscleweaknessareinvolved.Thecausemaybeprolongedpoor
posturalhabits,orthedysfunctionmaybearesultofcontracturesandadhesionsformedduringthe
healingoftissuesaftertraumaorsurgery.Stresstotheshortenedstructurescausespain.In
addition,strengthandflexibilityimbalancesmaypredisposetheareatoinjuryoroverusesyndromes
thatanormalmusculoskeletalsystemcouldsustain.
Posturalhabits.Goodposturalhabitsintheadultarenecessarytoavoidposturalpainsyndromes
andposturaldysfunction.Also,carefulfollowupintermsofflexibilityandposturetrainingexercises
isimportantaftertraumaorsurgerytopreventimpairmentsfromcontracturesandadhesions.Inthe
child,goodposturalhabitsareimportanttoavoidabnormalstressesongrowingbonesandadaptive
changesinmuscleandsofttissue.

CommonFaultyPostures:CharacteristicsandImpairments
Introduction
Thehead,neck,thorax,lumbarspine,andpelvisareallinterrelatedanddeviationsinoneregion
affecttheotherareas.Forclarityofpresentation,thelumbopelvicandcervicothoracicregionsand
typicalmusclelengthstrengthimpairmentsforeachregionaredescribedseparatelyinthissection.

PelvicandLumbarRegion
LordoticPosture
Lordoticposture(Fig.14.18A)ischaracterizedbyanincreaseinthelumbosacralangle(theangle
thatthesuperiorborderofthefirstsacralvertebralbodymakeswiththehorizontal,whichoptimally
is30),anincreaseinlumbarlordosis,andanincreaseintheanteriorpelvictiltandhipflexion.Itis
often
[Figure14.18.(A)Lordoticposturecharacterizedbyanincreaseinthelumbosacralangle,
increasedlumbarlordosis,increasedanteriortiltingofthepelvis,andhipflexion.(B)Relaxedor
slouchedposturecharacterizedbyexcessiveshiftingofthepelvicsegmentanteriorly,resultinginhip
extension,andshiftingofthethoracicsegmentposteriorly,resultinginflexionofthethoraxonthe
upperlumbarspine.Acompensatoryincreasedthoracickyphosisandforwardheadplacementare
alsoseen.(C)Flatlowbackposturecharacterizedbyadecreasedlumbosacralangle,decreased
lumbarlordosis,andposteriortiltingofthepelvis.(D)Flatupperbackandcervicalspine
characterizedbyadecreaseinthethoraciccurve,depressedscapulae,depressedclavicle,andan
exaggerationofaxialextension(flexionoftheocciputontheatlasandflatteningofthecervical
lordosis).]
seenwithincreasedthoracickyphosisandforwardheadandiscalledkypholordoticposture.41
PotentialMuscleImpairments
Mobilityimpairmentinthehipflexormuscles(iliopsoas,tensorfasciaelatae,rectusfemoris)and
lumbarextensormuscles(erectorspinae)
Impairedmuscleperformanceduetostretchedandweakabdominalmuscles(rectusabdominis,
internalandexternalobliques,andtransversusabdominis)
PotentialSourcesofSymptoms
Stresstotheanteriorlongitudinalligament.
Narrowingoftheposteriordiscspaceandnarrowingoftheintervertebralforamen.Thismay
compresstheduraandbloodvesselsoftherelatednerverootorthenerverootitself,especiallyif
therearedegenerativechangesinthevertebraorintervertebraldisc.
Approximationofthearticularfacets.Weightbearingthroughthefacetsmayincrease,whichmay
causesynovialirritationandjointinflammationandmayeventuallyacceleratedegenerativechanges

ifnotcorrected.
CommonCauses
Sustainedfaultyposture,pregnancy,obesity,andweakabdominalmusclesarecommoncauses.
RelaxedorSlouchedPosture
Therelaxedorslouchedposture(Fig.14.18B)isalsocalledswayback.41Theamountofpelvictilting
isvariable,butusuallythereisashiftingoftheentirepelvicsegmentanteriorly,resultinginhip
extension,andshiftingofthethoracicsegmentposteriorly,resultinginflexionofthethoraxonthe
upperlumbarspine.Thisresultsinincreasedlordosisinthelowerlumbarregion,increasedkyphosis
inthethoracicregion,andusuallyaforwardhead.Thepositionofthemidandupperlumbarspine
dependsontheamountofdisplacementofthethorax.Whenstandingforprolongedperiods,the
personusuallyassumesanasymmetricalstanceinwhichmostoftheweightisborneononelower
extremitywithpelvicdrop(lateraltilt)andhipabductionontheunweightedside.Thisaffectsfrontal
planesymmetry.
Asittingslouchedpostureoccurswhenthereisanoverallkyphoticcurvethroughouttheentire
thoracicandlumbarspine.
PotentialMuscleImpairments
Mobilityimpairmentintheupperabdominalmuscles(uppersegmentsoftherectusabdominisand
obliques),internalintercostal,hipextensor,andlowerlumbarextensormusclesandrelatedfascia
Impairedmuscleperformanceduetostretchedandweaklowerabdominalmuscles(lowersegments
oftherectusabdominisandobliques),extensormusclesofthelowerthoracicregion,andhipflexor
muscles
PotentialSourcesofSymptoms
Stresstotheiliofemoralligaments,theanteriorlongitudinalligamentofthelowerlumbarspine,and
theposteriorlongitudinalligamentoftheupperlumbarandthoracicspine.Withasymmetrical
postures,thereisalsostresstotheiliotibialbandonthesideoftheelevatedhip.Otherfrontalplane
asymmetriesmayalsobepresentandaredescribedinthefollowingsection.
Narrowingoftheintervertebralforameninthelowerlumbarspinethatmaycompresstheblood
vessels,dura,andnerveroots,especiallywitharthriticconditions.
Approximationofarticularfacetsinthelowerlumbarspine.
CommonCauses
Asthenameimplies,thisisarelaxedpostureinwhichthemusclesarenotusedtoprovidesupport.
Thepersonyieldsfullytotheeffectsofgravity,andonlythepassivestructuresattheendofeach
jointrange(e.g.,ligaments,jointcapsules,boneyapproximation)providestability.Causesmaybe
attitudinal(thepersonfeelscomfortablewhenslouching),fatigue(seenwhenrequiredtostandfor
extendedperiods),ormuscleweakness(theweaknessmaybethecauseortheeffectofthe
posture).Apoorlydesignedexerciseprogramonethatemphasizesthoracicflexionwithout
balancingstrengthwithotherappropriateexercisesandposturaltrainingmayperpetuatethese
impairments.
FlatLowBackPosture
Flatlowbackposture(Fig.14.18C)ischaracterizedbyadecreasedlumbosacralangle,decreased
lumbarlordosis,hipextension,andposteriortiltingofthepelvis.
PotentialMuscleImpairments
Mobilityimpairmentinthetrunkflexor(rectusabdominis,intercostals)andhipextensormuscles
Impairedmuscleperformanceduetostretchedandweaklumbarextensorandpossiblyhipflexor
muscles
PotentialSourcesofSymptoms
Lackofthenormalphysiologicallumbarcurve,whichreducestheshockabsorbingeffectofthe

lumbarregionandpredisposesthepersontoinjury
Stresstotheposteriorlongitudinalligament
Increaseoftheposteriordiscspace,whichallowsthenucleuspulposustoimbibeextrafluidand,
undercertaincircumstances,mayprotrudeposteriorlywhenthepersonattemptsextension.This
increasedweightbearingonthediscmayleadtodegenerativechanges.
CommonCauses
Continuedslouchingorflexioninsittingorstandingposturesoveremphasisonflexionexercisesin
generalexerciseprograms
Figure14.18.(A)Lordoticposturecharacterizedbyanincreaseinthelumbosacral
angle,increasedlumbarlordosis,increasedanteriortiltingofthepelvis,andhip
flexion.(B)Relaxedorslouchedposturecharacterizedbyexcessiveshiftingofthe
pelvicsegmentanteriorly,resultinginhipextension,andshiftingofthethoracic
segmentposteriorly,resultinginflexionofthethoraxontheupperlumbarspine.A
compensatoryincreasedthoracickyphosisandforwardheadplacementarealso
seen.(C)Flatlowbackposturecharacterizedbyadecreasedlumbosacralangle,
decreasedlumbarlordosis,andposteriortiltingofthepelvis.(D)Flatupperback
andcervicalspinecharacterizedbyadecreaseinthethoraciccurve,depressed
scapulae,depressedclavicle,andanexaggerationofaxialextension(flexionofthe
occiputontheatlasandflatteningofthecervicallordosis).

CervicalandThoracicRegion
RoundBack(IncreasedKyphosis)withForwardHead
Theroundbackwithforwardheadposture(seeFig.14.18B)ischaracterizedbyanincreased
thoraciccurve,protractedscapulae(roundshoulders),andforward(protracted)head.Aforward
headinvolvesincreasedflexionofthelowercervicalandtheupperthoracicregions,increased
extensionoftheuppercervicalvertebra,andextensionoftheocciputonC1.Therealsomaybe
temporomandibularjointdysfunctionwithretrusionanddepressionofthemandible.
PotentialMuscleImpairments
Mobilityimpairmentinthemusclesoftheanteriorthorax(intercostalmuscles),musclesoftheupper
extremityoriginatingonthethorax(pectoralismajorandminor,latissimusdorsi,serratusanterior),
musclesofthecervicalspineandheadthatattachedtothescapulaandupperthorax(levator
scapulae,sternocleidomastoid,scalene,uppertrapezius),andmusclesofthesuboccipitalregion
(rectuscapitisposteriormajorandminor,obliquuscapitisinferiorandsuperior)
Impairedmuscleperformanceduetostretchedandweaklowercervicalandupperthoracicerector
spinaeandscapularretractormuscles(rhomboids,middletrapezius),anteriorthroatmuscles
(suprahyoidandinfrahyoidmuscles),andcapitalflexors(rectuscapitisanteriorandlateralis,
superiorobliquelonguscolli,longuscapitis)
Withtemporomandibularjointsymptoms,themusclesofmastication(pterygoid,masseter,
temporalismuscles)mayexperienceincreasedtension.
PotentialSourcesofSymptoms
Stresstotheanteriorlongitudinalligamentintheuppercervicalspineandtotheposterior
longitudinalligamentandligamentumflavuminthelowercervicalandthoracicspine
Fatigueofthethoracicerectorspinaeandscapularretractormuscles
Irritationoffacetjointsintheuppercervicalspine
Narrowingoftheintervertebralforaminaintheuppercervicalregion,whichmayimpingeonthe
bloodvesselsandnerveroots,especiallyiftherearedegenerativechanges.

Impingementontheneurovascularbundlefromanteriorscaleneorpectoralisminormuscletightness
(see"ThoracicOutletSyndrome"inChapter13)
Strainontheneurovascularstructuresofthethoracicoutletfromscapularprotraction40
Impingementofthecervicalplexusfromlevatorscapulaemuscletightness
Impingementonthegreateroccipitalnervesfromatightortenseuppertrapeziusmuscle,leadingto
tensionheadaches
Temporomandibularjointpainfromjointcompressionduetomandibularmalalignmentandassociated
facialmuscletension
Lowercervicaldisclesionsfromthefaultyflexedposture
CommonCauses
Theeffectsofgravity,slouching,andpoorergonomicalignmentintheworkorhomeenvironment.
Occupationalorfunctionalposturesrequiringleaningforwardortippingtheheadbackwardfor
extendedperiodsfaultysittingpostures,suchasworkingatanimproperlyplacedcomputer
keyboardorscreen,relaxedpostures,ortheendresultofafaultypelvicandlumbarspineposture
arecommoncausesofforwardheadposture.Causesaresimilartotherelaxedlumbarpostureor
theflatlowbackpostureinwhichthereiscontinuedslouchingandoveremphasisonflexion
exercisesingeneralexerciseprograms.
FlatUpperBackandNeckPosture
Theflatupperbackandneckposture(Fig.14.18D)ischaracterizedbyadecreaseinthethoracic
curve,depressedscapulae,depressedclavicles,anddecreasedcervicallordosiswithincreased
flexionoftheocciputonatlas.Itisassociatedwithanexaggeratedmilitaryposturebutisnota
commonposturaldeviation.Theremaybetemporomandibularjointdysfunctionwithprotractionof
themandible.
PotentialMuscleImpairments
Mobilityimpairmentintheanteriorneckmuscles,thoracicerectorspinae,andscapularretractors,
andpotentiallyrestrictedscapularmovement,whichdecreasesthefreedomofshoulderelevation
Impairedmuscleperformanceinthescapularprotractorandintercostalmusclesoftheanterior
thorax
PotentialSourcesofSymptoms
Fatigueofmusclesrequiredtomaintaintheposture
Compressionoftheneurovascularbundleinthethoracicoutletbetweentheclavicleandribs
Temporomandibularjointpainandocclusivechanges
Decreaseintheshockabsorbingfunctionofthekypholordoticcurvature,whichmaypredisposethe
necktoinjury
CommonCause
Asnoted,thisisnotacommonposturaldeviationandoccursprimarilywithexaggerationofthe
militaryposture.

FrontalPlaneDeviations:ScoliosisandLowerExtremityAsymmetries
Scoliosis
Scoliosisisdefinedasalateralcurvatureinthespine.Itusuallyinvolvesthethoracicandlumbar
regions.Typically,inrighthandedindividuals,thereisamildrightthoracic,leftlumbarScurve,ora
mildleftthoracolumbarCcurve.Theremaybeasymmetryinthehips,pelvis,andlowerextremities.

Structuralscoliosis.Structuralscoliosisinvolvesanirreversiblelateralcurvaturewithfixed
rotationofthevertebrae(Fig.14.19A).Rotationofthevertebralbodiesistowardtheconvexityof
thecurve.Inthethoracicspine,theribsrotatewiththevertebrae,sothereisprominenceoftheribs
posteriorlyonthesideofthespinalconvexityandprominenceanteriorlyonthesideoftheconcavity.
Aposteriorribhumpisdetectedonforwardbendinginstructuralscoliosis(Fig.14.19B).44
Nonstructuralscoliosis.Nonstructuralscoliosisisreversibleandcanbechangedwithforwardor
sidebendingandwithpositionalchanges,suchaslyingsupine,realignmentofthepelvisby
correctionofaleglengthdiscrepancy,orwithmusclecontractions.Itisalsocalledfunctionalor
posturalscoliosis.
[Figure14.19.(A)Mildrightthoracicleftlumbarstructuralscoliosiswithprominenceoftheright
scapula.(B)Forwardbendingproducesaslightposteriorribhump,indicatingfixedrotationofthe
vertebraeandribcage.]
PotentialImpairments
Mobilityimpairmentinjoints,muscles,andfasciaontheconcavesideofthecurves
Impairedmuscleperformanceduetostretchandweaknessinthemusculatureontheconvexsideof
thecurves
Ifonehipisadducted,theadductormusclesonthatsidehavedecreasedflexibility,andtheabductor
musclesarestretchedandweak.Theoppositeoccursonthecontralateralextremity.41
Withadvancedstructuralscoliosis,thereisdecreasedribexpansioncardiopulmonaryimpairments
mayresultindifficultybreathing.
PotentialSourcesofSymptoms
Musclefatigueandligamentousstrainonthesideoftheconvexity
Nerverootirritationonthesideontheconcavity
Jointirritationfromapproximationofthefacetsonthesideoftheconcavity
CommonCauses:StructuralScoliosis
Neuromusculardiseasesordisorders(e.g.,cerebralpalsy,spinalcordinjury,progressive
neurologicalormusculardiseases),osteopathicdisorders(e.g.,hemivertebra,osteomalacia,rickets,
fracture),andidiopathicdisordersinwhichthecauseisunknownarecommoncausesofstructural
scoliosis.
CommonCauses:NonstructuralScoliosis
Leglengthdiscrepancy(structuralorfunctional),muscleguardingorspasmfromapainfulstimuliin
thebackorneck,andhabitualorasymmetricalposturesarecommoncausesofnonstructural
scoliosis.
FrontalPlaneDeviationsfromLowerExtremityAsymmetries
Anylowerextremityinequalityhasaneffectonthepelvisthat,inturn,affectsthespinalcolumnand
structuressupportingit.18Whendealingwithspinalposture,itisimperativetoassesslower
extremityalignment,symmetry,footposture,ROM,muscleflexibility,andstrength.SeeChapters20
through22forprinciples,procedures,andtechniquesfortreatingthehip,knee,ankle,andfoot.
Frontalplanedeviationsmayalsobeseenwithfaultyposturalhabitssuchasperpetuallystanding
withapelvicdropononesideasfrequentlyseenwithrelaxedpostures.Thismayresultinmuscle
imbalancesinthehipandspineandanapparentleglengthdiscrepancy.
CharacteristicDeviations(Fig.14.20)
Whenstandingwithweightequallydistributedtobothlowerextremities,anelevatediliumonthe
longleg(LL)sideandloweredontheshortleg(SL)sideisthecharacteristicdeviation.
[Figure14.20.Frontalplaneasymmetries.Picturedisanindividualwithalonglegandelevated
iliumontherightside.Typically,hipadduction,verticalsacroiliac(SI)joint,sidebendingtowardand
rotationoppositethatofthelumbarspine,andcompensationsinthoracicandcervicalspineareseen

onthelonglegside.]
ThisputstheLLsideinhipadductionwithgreatershearstressandtheSLsideinhipabductionwith
greatercompressionstress.
Thesacroiliac(SI)jointontheLLsideismoreverticalwithgreatershearstressontheSLside,itis
morehorizontalwithgreatercompressionstress.
SidebendingofthelumbarspinetowardtheLLsidecoupledwithrotationintheoppositedirection
ThiscompressestheintervertebraldiscontheLLsideanddistractsthediscontheSLsideitalso
causestorsionalstress.
ThereisextensionandcompressionofthelumbarfacetsontheLLside(concaveportionofthecurve)
andflexionanddistractionofthelumbarfacetsontheSLside(convexportionofthecurve).
ThereisnarrowingoftheintervertebralforaminaontheLLside.
Thethoracicandcervicalspinehascompensatoryscoliosisintheoppositedirection.
PotentialMuscleImpairments
MobilityimpairmentfromdecreasedflexibilityinthehipadductorsontheLLsideandabductorson
theSLside.Theremayalsobeasymmetricaldifferencesintheiliopsoas,quadratuslumborum,
piriformis,erectorspinae,andmultifidusmuscles,withthoseontheconcavesideofthecurveorthe
LLsidehavingdecreasedflexibility.
Impairedmuscleperformancefromstretchedandweakenedmusclesthattypicallyincludeship
adductorsontheSLside,abductorsontheLLside,andingeneralmusclesontheconvexsideofthe
curve.
PotentialSourcesofSymptoms
GreatershearforcesoccurinthehipandSIjointsontheLLside,whichincreasesstressinthe
supportingligamentsanddecreasestheloadbearingsurfaceinthejoint.Degenerativechanges
occurmorefrequentlyinhipsontheLLside.17
StenosisinthelumbarintervertebralforaminaontheLLsidemaycausevascularcongestionornerve
rootirritation.
LumbarfacetcompressionandirritationontheLLsideleadingtoearlydegenerativechanges.
Intervertebraldiscbreakdownfromtorsionalandasymmetricalforces.
Muscletension,fatigue,orspasminresponsetoasymmetricalloadingandresponse.
Lowerextremityoverusesyndromes.
CommonCauses
Asymmetryinthelowerextremitiesmayresultfromstructuralorfunctionaldeviationsatthehip,
knee,ankle,orfoot.Commonfunctionalproblemsincludeunilateralflatfootandimbalancesinthe
flexibilityofmuscles.Theresultingasymmetricalgroundreactionforcestransmittedtothepelvis
andbackmayleadtotissuebreakdownandoveruse,particularlyasapersonages,becomes
overweight,orisgenerallydeconditionedfrominactivity.
Figure14.19.(A)Mildrightthoracicleftlumbarstructuralscoliosiswith
prominenceoftherightscapula.(B)Forwardbendingproducesaslightposteriorrib
hump,indicatingfixedrotationofthevertebraeandribcage.

Figure14.20.Frontalplaneasymmetries.Picturedisanindividualwithalongleg
andelevatediliumontherightside.Typically,hipadduction,verticalsacroiliac(SI)

joint,sidebendingtowardandrotationoppositethatofthelumbarspine,and
compensationsinthoracicandcervicalspineareseenonthelonglegside.

ManagementofImpairedPosture
Introduction
Faultypostureunderliesmanyspinalandextremitydisordersandfunctionalrestrictions.Oftenby
simplycorrectingtheunderlyingposturalstresses,theprimarysymptomscanbeminimizedoreven
alleviated.Becauseofthisthefollowingguidelinesmaybecomepartofmostrehabilitation
programs.Exercisesforusewithposturalimpairmentsareidentifiedinthissectionandare
describedindetailintherespectivechaptersthatfollow.

GeneralManagementGuidelines
Introduction
Beforedevelopingaplanofcareandselectinginterventionsformanagement,evaluatethefindings
fromtheexaminationofthepatient,includingthehistory,reviewofsystems,andspecifictestsand
measures,anddocumentthefindings.
Posturalalignment(sittingandstanding),balance,andgait
ROM,jointmobility,andflexibility
Muscularstrengthandenduranceforrepetitionsandholding
Ergonomicassessmentifindicated
Bodymechanics
Cardiopulmonaryendurance/aerobiccapacity,breathingpattern
Commonimpairmentsandasummaryoftheinformationthatfollowsonmanagementofpatients
withimpairedposturearesummarizedinBox14.1.

AwarenessandControlofSpinalPosture
Initially,goodspinalposturemaybepreventedbecauseofrestrictedmobilityofmuscle,connective
tissue,orvertebralsegment,butdevelopingpatientawarenessofbalancedpostureanditseffects
shouldbeginassoonaspossibleinthetreatmentprograminconjunctionwithstretchingandmuscle
trainingmaneuvers.
PostureTrainingTechniques
Isolateeachbodysegmentandtrainthepatienttoproperlymovethatsegment.Ifoneregionisout
ofalignment,itislikelythattherearecompensatorydeviationsinthealignmentthroughoutthe
spine.Therefore,totalposturecorrection,includingupperandlowerextremityalignment,shouldbe
emphasized.Directthepatient'sattentiontothefeelofpropermovementandmusclecontraction
andrelaxation.Anothertechniqueistohavethepatientassumeanextremecorrectedposture,then
easeawayfromtheextremetowardmidposition,andfinallyholdthecorrectedposture.Useverbal,
tactile,andvisualreinforcementcuessuchas:
Verbalreinforcement.Asyouinteractwiththepatient,frequentlyinterpretthesensationsof
musclecontractionandspinalpositionsthatheorsheshouldbefeeling.

Tactilereinforcement.Helpthepatientpositiontheheadandtrunkincorrectalignmentandtouch
themusclesthatneedtocontracttomoveandholdthepartsinplace.
Visualreinforcement.Usemirrorssothepatientcanseehowheorshelooks,whatittakesto
assumecorrectalignment,andthenhowitfeelswhenproperlyaligned.
AxialExtension(CervicalRetraction)toDecreaseaForwardHeadPosture
Patientpositionandprocedure:Sittingorstanding,witharmsrelaxedattheside.Lightlytouch
abovethelipunderthenoseandaskthepatienttolifttheheadupandawayasifastringwas
pullingtheirheadupward(Fig.14.21A).Verballyreinforcethecorrectposture,anddrawattentionto
thewayitfeels.Havethepatientmovetotheextremeofthecorrectpostureandthenreturnto
midline.
Box14.1MANAGEMENTGUIDELINESImpairedPosture
StructuralandFunctionalImpairments
Painfrommechanicalstresstosensitivestructuresandfrommuscletension
Impairedmobilityfrommuscle,joint,orfascialrestrictions
Impairedmuscleperformanceassociatedwithanimbalanceinmusclelengthandstrengthbetween
antagonisticmusclegroups
Impairedmuscleperformanceassociatedwithpoormuscularendurance
Insufficientposturalcontrolofscapularandtrunkstabilizingmuscles
Decreasedcardiopulmonaryendurance
Alteredkinestheticsenseofpostureassociatedwithpoorneuromuscularcontrolandprolongedfaulty
posturalhabits
Lackofknowledgeofhealthyspinalcontrolandmechanics
PlanofCare
1. Developawarenessand
controlofspinalposture

Intervention
1. Kinesthetictrainingcervicalandscapularmotions,pelvictilts,
controlofneutralspine.Utilizeprocedurestodevelopand
reinforcecontrolofposturewhensitting,standing,walking,and
performingtargetedfunctionalactivities
2. Practicepositionsandmovementstoexperiencecontrolof
symptomswithvariouspostures

2. Educatethepatientabout
therelationshipbetween
faultypostureand
symptoms
3. Increasemobilityin
3. Manualstretchingandjointmobilization/manipulationteachself
restrictingmuscles,joints,
stretching
fascia
4. Developneuromuscular
4. Stabilizationexercisesprogressrepetitionsandchallengewith
control,strength,and
extremitymotionsprogresstodynamictrunkstrengthening
enduranceinposturaland
exercises
extremitymuscles
5. Teachsafebody
5. Functionalexercisestoprepareforsafemechanics(squatting,
mechanics
lunges,reaching,pushing/pulling,liftingandturningloadswith
stablespine)
6. Ergonomicassessmentof 6. Adaptwork,home,recreationalenvironment
home,work,recreational
environments
7. Stress
7. Relaxationexercisesandposturalstressrelief
management/relaxation
8. Identifysafeaerobic
8. Implementandprogressanaerobicexerciseprogram

activities
9. Promotehealthyexercise
habitsforself
maintenance

9. Integrationofafitnessprogram,regularexercise,andsafebody
mechanicsintodailylife

ScapularRetraction
Patientpositionandprocedure:Sittingorstanding.Fortactileandproprioceptivecues,gentlyresist
movementoftheinferiorangleofthescapulaeandaskthepatienttopinchthemtogether
(retraction).Suggestthatthepatientimagine"holdingaquarterbetweentheshoulderblades."The
patientshouldnotextendtheshouldersorelevatethescapulae(Fig.14.21B).
PelvicTiltandNeutralSpine
Patientpositionandprocedure:Sitting,thenstandingwiththebackagainstawall.Teachthepatient
torollthepelvisforwardandbackwardtoisolateananteriorandposteriorpelvictilt.Afterthe
patienthaslearnedtoisolatethemovement,instructhimorhertopracticecontrolofthepelvisand
lumbarspinebymovingfromextremelordosistoextremeflatbackandthenassumemildlordosis.
Identifythemidpositionasthe"neutralspine,"sothepatientbecomesfamiliarwiththeterm.Show
thatthehandshouldbeabletoeasilyslipbetweenthebackandthewallandthatheorshecanthen
feelthebackwithonesideofthehandandthewallwiththeotherside.Ifthepatienthasdifficulty
tiltingthepelvis,suggestthatheorsheimaginethatthepelvisisabushelbasketwitharounded
bottomandthewaististherimofthebasket.Havethepatientthenimagineandpracticetippingthe
"basket"forwardandbackwardandthenfindingtheneutralspineposition.
[Figure14.21.Trainingthepatienttocorrect(A)forwardheadpostureand(B)protracted
scapulae.]
ThoracicSpine
Patientpositionandprocedure:Standing.Thepositionofthethoraxaffectsthepostureofthelumbar
spineandpelvisconsequently,thefeelofthoracicmovementisincorporatedinposturetrainingfor
thelumbarspine.Asthepatientassumesamildlylordoticposture,havehimorherbreatheinand
lifttheribcage(extension).Guidehimorhertoabalancedposture,notanextremelyextended
posture.Standingwiththebackagainstawall(asinthepelvictilttrainingabove)encourages
thoracicextension.
TotalSpinalMovementandControl
Patientpositionandprocedure:Sittingorstanding.Instructthepatienttocurltheentirespineby
firstflexingtheneck,thenthethorax,andthenthelumbarspine.Givecuesforunrollingbyfirst
touchingthelumbarspineasthepatientextendsit,thenthethoracicspineasheorsheextendsit
andtakesinabreathtoelevatetheribcage.Thendirectattentiontoadductingthescapulaewhile
yougentlyresistthemotionandthenliftingtheheadinaxialextensionwhileyougiveslight
pressureagainsttheupperlip(seeFig.14.21).Verballyandvisuallyreinforcethecorrectposture
whenitisobtained.
Reinforcement.Itisnotpossibleforapersonalwaystomaintaingoodposture.Therefore,to
reinforceproperperformance,teachthepatienttousecuesthroughoutthedaytocheckposture.For
example,instructthepatienttocheckthepostureeverytimeheorshewalkspastamirror,waitsat
aredtrafficlightwhiledrivingacar,sitsdownforameal,entersaroom,orbeginstalkingwith
someone.Findoutwhatdailyroutinesthepatienthasthatcouldbeusedforreinforcementor
remindersinstructthepatienttopracticeandreporttheresults.Providepositivefeedbackasthe
patientbecomesactivelyinvolvedintherelearningprocess.
Posturalsupport.Ifnecessary,provideexternalsupportwithaposturalsplintortapetoprevent
theextremepostureofroundshouldersandprotractedscapulae.Thesesupportshelptraincorrect
musclefunctioningbyactingasareminderforthepatienttoassumecorrectposturewhenheorshe
slouches.Also,bypreventingthepositionofstretchfromoccurring,stretchweaknesscanbe
corrected.Thesedevicesshouldbeusedonlyonatemporarybasisfortrainingsothepatientdoes
notbecomedependentonthem.
Figure14.21.Trainingthepatienttocorrect(A)forwardheadpostureand(B)
protractedscapulae.

Posture,Movement,andFunctionalRelationships
Oncethepatienthaslearnedhowtoassumecorrectpostures,itisimportanttohavehimorher
experiencetheeffectsustainedorrepetitivefaultypostureshaveonpainandfunction,followedby
theirabilitytoaltertheseaffectsbycorrectingtheirposture.
Relationshipofimpairedpostureandpain.Havethepatientassumethefaultypostureandwait.
Whenheorshebeginstofeeldiscomfort,pointoutthepostureandtheninstructhowtocorrectit
andnoticethefeelingofrelief.Manypatientsdonotacceptsuchasimplerelationshipbetween
stressandpain,sodrawtheirattentiontonoticingwhatposturetheyarein(includingwhenatwork,
home,driving/ridinginacar,orinbed)whentheirsymptomsdevelopandhowtheycancontrolthe
discomfortwiththefollowingtechniques.
Relationshipofimpairedpostureandextremityfunction.Havethepatientassumetheirfaulty
postureandattemptafunctionalactivitysuchasreachingupwardwiththeirupperextremity,moving
theirlowerextremity,oropeningandclosingtheirjaw.Theythenassumeacorrectedposture,
repeatthesameactivity,andnotethedifference.Oncetheimprovedrangeandqualityofmovement
areexperienced,reinforcethem,sothepatientcanunderstandthevalueofdevelopingand
maintaininggoodalignmentwhenperformingfunctionalactivities.

Joint,Muscle,andConnectiveTissueMobilityImpairments
Commonmuscleimbalancesinlengthandstrengthweredescribedintheprevioussectionon
impairedpostures.Itiscriticalthatspecificmobilityrestrictionsareidentifiedsothatstretching
techniquescanbeselective.Forexample,thetransitionareasbetweenthecervicothoracic,
thoracolumbar,andlumbosacralregionstypicallyhavegreatermobility.Whenfaultyposturalhabits
dominate,thesegmentalmobilityintheseareastendstobecomeexaggeratedinthedirectionofthe
faultyposture.Stretchingshouldproceedcautiouslysoasnottoaccentuatetheproblemwhile
attemptingtocorrectthetissueswithdecreasedmobility.Stretchingtechniquesforthecervical,
thoracic,andlumbarregionsaredescribedinChapter16.Specificspinalmobilization/manipulation
techniquesdirectedatspecifichypomobilesegmentsaredescribedinChapters15and16.Although
anystructurecouldbeinvolved,particularlyfollowinganinjuryorpathologicalcondition,themuscle
flexibilityimpairmentsmosttypicallyseenareidentifiedinBox14.2.Includedarereferencesfor
selfstretching/flexibilityexercisesforeachmusclegroup.Specificinstructionsandprecautionsare
describedinthetextaccompanyingthepicturesintherespectivechapters.
Box14.2StretchingTechniquesforCommonMobilityImpairments
Suboccipitalregion:selfstretchwithcapitalnoddingpatientapplyagentlestretchagainstthe
occiputwiththelateralborderofthehand
Levatorscapulae:selfstretchwithscapulardepressionandcervicalflexionandrotationtothe
oppositeside(seeFig.17.35inChapter17)
Scalenes:selfstretchwithaxialextension,sidebendneckoppositeandthenrotatenecktowardside
ofrestriction(seepositionFig.16.3inChapter16).
Pectoralismajorandanteriorthorax:selfstretchwithcornerstretches(seeFig.17.31inChapter17)
orwhilelyingsupineonafoamrollplacedlongitudinallyunderthespine(seeFig.16.1BinChapter
16)
Latissimusdorsi:selfstretchlyingsupineonafoamroll,reacharmsoverhead(seeFig.16.1Ain
Chapter16)
Lumbarandhipextensors:selfstretchlyingsupine,bringkneestochestorquadrupedposition,
movebuttocksbackoverthefeet(seeFigs.16.13and16.14inChapter16)

Lumbarflexors:selfstretchwithpronepressupsorstandingbackbends(seeFig.16.15inChapter
16).
HipFlexors:selfstretchlyingsupineinThomaspositionorstandinginmodifiedfencer'ssquat(see
Figs.20.10and20.11inChapter20).
Tensorfascialata:selfstretcheithersupine,sidelying,orstandingextend,laterallyrotate,then
adductthehip(seeFigs.20.19,20.20,and20.21inChapter20).
Iliotibialbandfoamrollstretch:sidelieonafoamrollplacedperpendiculartothethigh,gentlyroll
thethighbackandforthwithbodyweightapplyingthestretchforce(seeFig.21.22inChapter21).
Pyriformis:selfstretchlyingsupineorsittingandbringingtheflexedkneetowardtheopposite
shoulder.Flex,adduct,andinternallyrotatethehip(seeFig.20.15inChapter20).
Hamstrings:selfstretchwithastraightlegmaneuvereitherlyingsupineorlongsitting(seeFigs.
20.17and20.18inChapter20).
Gastrocsoleus(heelcords):selfstretchinaforwardstridepositionwiththeheelofthebackleg
maintainedonthefloor,orstandonaninclineboardoredgeofastep(seeFig.22.8inChapter22).

Figure16.1.Foamrollstretchtoincreaseflexibilityofanteriorthorax.(A)Inthe
"touchdown"position,theshoulderextensorsarealsostretched.(B)Withthe
shouldersabductedandlaterallyrotated,thepectoralismajorandotherinternal
rotatorsarealsostretched.Foralessintensivestretch,usearolledtowelplaced
longitudinallyunderthespine.

Figure16.3.Unilateralactivestretchingofthescalenusmuscles(manualstretch).
Thepatientfirstperformsaxialextension,thensidebendstheneckoppositeand
rotatesittowardthetightmuscles.Thetherapiststabilizestheheadandupper
thoraxasthepatientbreathesin,contractingthemuscleagainstthetherapist's
resistance.Asthepatientrelaxes,theribcagelowersandstretchesthemuscle.

Figure16.13.Selfstretchingthelumbarerectorspinaemusclesandtissues
posteriortothespine.Thepatientgraspsaroundthethighstoavoidcompressionof
thekneejoints.

Figure16.14.Stretchingofthelumbarspine.(A)Thepatientperformsaposterior
pelvictiltwithoutroundingthethorax.(B)Thepatientmovesthebuttocksbackover
thefeetforagreaterstretch.

Figure16.15.Selfstretchingofthesofttissuesanteriortothelumbarspineand
hipjointswiththepatient(A)prone(usingapressup)and(B)standing.

Figure17.31.Selfstretchingthepectoralismajormusclewiththearmsina
reverseTpositiontostretch(A)theclavicularportionandinaVpositiontostretch
(B)thesternalportion.

Figure17.35.Selfstretchingofthelevatorscapulaemuscle(A)usingupward

rotationofthescapulaand(B)usingdepressionofthescapula.

Figure20.10.Selfstretchingtoincreasehipextension.Thepelvisisstabilizedby
holdingtheoppositehipinflexion.Theweightofthethighprovidesastretchforce
asthepatientrelaxes.Allowingthekneetoextendemphasizestheonejointhip
flexors(iliopsoas),whereasmaintainingthekneeinflexionandhipneutralto
rotationasthethighisloweredemphasizesthetwojointrectusfemorisandtensor
fasciaelataemuscles.
Figure20.11.Selfstretchingofthehipflexormusclesandsofttissueanteriorto
thehipusingamodifiedfencer'ssquatposture.

Figure20.15.Selfstretchingtoincreaseinternalrotationofthehip.

Figure20.17.Selfstretchingofthehamstringmuscles.Additionalstretchcanoccur
ifthepersoneither(A)movesthebuttockclosertothedoorframeor(B)liftsthe
legawayfromthedoorframe.

Figure20.18.Selfstretchingthehamstringmusclesbyleaningthetrunktoward
theextendedknee,flexingatthehips.

Figure20.19.Selfstretchingofthetensorfascialatae:supine.Pillowssupportthe
spineandpelvis,allowingthehipstoextend.Thecrossedoverfootstabilizesthe
femurinadductionandexternalrotation.
Figure20.20.Selfstretchingofthetensorfascialatae:sidelying.(A)Thethighis
abductedintheplaneofthebodythenitisextendedandexternallyrotated,then
slowlylowered.Additionalstretchoccursbyflexingtheknee.(B)Progressthe
intensityofasustainedstretchbypullingthehipintoextensionwithastrapand
addingaweight.
Figure20.21.Selfstretchingofthetensorfasciaelatae:standing.Thepelvisshifts
towardthetightsidewithaslightsidebendofthetrunkawayfromthetightside.
Increasedstretchoccurswhentheextremityispositionedinexternalrotationprior
tothestretch.

Figure21.22.FoamrollerfascialreleaseforatightITband.

Figure22.8.LateralviewoftheankledepictingreconstructionoftornATFandCF

ligamentsusingatendongrafttoaugmentstability.Proximaladvancementand
suturingoftheextensorretinaculum(notshown)overthereconstructedligaments
tothedistalfibulaprovideadditionalstability.

ImpairedMusclePerformance
Typicallyimpairedposturalmusclesthatsupportthebodyinsustainedposturessuccumbtothe
effectsofgravity,becomelessactive,56anddevelopstretchweakness.41Strengtheningalonedoes
notcorrectthisproblem,soanyexercisesmustbedoneinconjunctionwithposturetrainingfor
control,asdescribedearlierinthissection.Inaddition,exercisesformuscularenduranceare
necessarytopreparethemusclestofunctionoveranextendedperiodoftime.Finally,environmental
adaptationsmustbemadetominimizethestressesofsustainedandrepetitivepostures.Muscles
thattypicallydemonstratestretchweaknessorpoorposturalenduranceareidentifiedinBox14.3.
Indepthdescriptionsoftheexercisesareinthechaptersidentified.
Box14.3TrainingandStrengtheningTechniquesforCommonMuscleImpairments
Activateandlearncontrolofthelonguscollianddeepcapitalflexors(seeFigs.16.39Band16.59in
Chapter16)
Lowercervicalextension(seeFig.16.40inChapter16)
Scapularretractionandshoulderlateralrotation(seeFig.16.45inChapter16andFigs.17.46and
17.47inChapter17)
Lumbarspinalstabilization(seeFigs.16.47through16.56plusaccompanyingtextinChapter16)
Hipabductionposteriorgluteusmediusbeginsidelying,progresstostanding.Placeemphasison
maintainingthehipinextensionwithslightlateralrotationwhileabducting(seeFig.20.26Bin
Chapter20).

Figure16.39.(A)TheStabilizerpressurebiofeedbackunit(2006Encore
Medical,L.P.)isusedtoprovidevisualfeedbacktothepatientwhiletrainingfor
spinalstabilization.(B)Stabilizerfoldedintothirdsunderthecervicalspinetotest
andtraincapitalflexionwithneutralspineaxialextension.
Figure16.40.Axialextension(cervicalretraction)exercises.

Figure16.45.Limbloadingforbasicstabilizationprogressionofcervical
musculatureinproneposition.Maximumprotectionphase:(A)armsatside,
shoulderlateralrotation,andscapularadduction(B)armsat90/90,horizontal
abduction,andscapularadduction.Moderateprotectionphase:(C)shoulder
elevationfullrange,(D)shoulders90withlateralrotationandelbowextended,
horizontalabduction,andscapularadduction.
Figure16.47.Bentlegfallout.Level2limbloadingforbasicstabilizationofthe
abdominalmusclesinthesupineposition.Thisrequirescontroltopreventpelvic
rotationstabilityisassistedbytheoppositelowerextremitywhilehooklying.
VIDEO16.17
Figure16.56.Activationofthestabilizingtrunkmusclesoccurstomaintainbalance
onafoamrollwhiletheextremitiesmoveinvariousplanes:(A)shoulderhorizontal

abduction/adductionand(B)ipsilateralhipandshoulderflexion/extensionare
shown.Weightsareaddedtoincreasethechallenge.

Figure16.59.Trainingtheshortcervicalflexorswhiledeemphasizingthe
sternocleidomastoidforcervicalflexiontoregainabalanceinstrengthforanterior
cervicalstabilization.
Figure17.46.Cornerpressouttostrengthenscapularretractionandshoulder
horizontalabduction(viewfromabove).

Figure17.47.Combinedscapularretractionwithshoulderhorizontalabductionand
externalrotationagainstresistance.

Figure20.26.Closedchainstabilizationandstrengtheningexerciseswithelastic
resistancearoundtheoppositeleg.(A)Resistingextensionontherightrequires
stabilizationoftheanteriormusclesoftheleftside.(B)Resistingabductiononthe
rightrequiresstabilizationbytheleftfrontalplanemuscles.Toincreasedifficulty,
theresistanceismoveddistallyontotheleg.

BodyMechanics
Musclestrengtheningforsafebodymechanicsincludesnotonlystrengtheningspecificmusclesbut
alsofunctionalactivitiesthatpreparethebodyforspecificstressesthatitisrequiredtodofora
particularfunction,asidentifiedinBox14.4.Instructioninbodymechanicsisdescribedindetailin
Chapter16inthesection"FunctionalTraining."

Ergonomics:ReliefandPrevention
Itiscriticaltohelpthepatientadaptposturesandactivitiesthatareperformedonasustainedor
repetitivebasisatwork,athome,recreationally,orsociallyiftheyarecontributingtothepostural
stressesandmusculoskeletaldisorders.55Itmaybenecessarytousealumbarpillowforsupportor
tomodifytheworkenvironment(workstation)torelievesustainedstressfulpostures.Thereare
manyresources,suchastheOccupationalSafetyandHealthAdministration(OSHA)website
(http://www.osha.gov/SLTC/ergonomics/)andothers(http://ergo.human.cornell.edu/)thatprovide
informationonergonomicassessmentandadaptationtoworkenvironmentstorelieveposturalstress
andmusculoskeletaldisorders.
Box14.4FunctionalExercisesinPreparationforSafeBodyMechanics
Upperextremitypullingandpushing(seeFig.17.58inChapter17)
Wallslidesprogresstosquattingandsquattingwithlifting(seeFig.20.29inChapter20)
Lungesprogresstolungeswithliftingandwithpushingandpulling(seeFig.20.32inChapter20and
Figs.23.31and23.62inChapter23).

FocusonEvidence
Thereisstrongevidence,documentedina3yearprospectivestudyof632newlyhiredcomputer
users,thatacomputerworkstationmaybethesourceofsymptomsifthechair,desk,keyboard,
mouse,andmonitorareimproperlypositionedfortheindividual.20,46Thereisalsomixedevidence,
summarizedinasystematicstudyoftheliteratureontherelationshipofpostureandrepetitive
stressesintheworkenvironment,regardingthedevelopmentoflowbackpain.69

Figure17.58.Pushingaweightedcarttosimulateafunctionalactivityand
incorporateproperbodymechanics.

Figure20.29.Wallslides/partialsquatstodevelopeccentriccontrolofbodyweight.
(A)Thebackslidingdownawall,superimposingbilateralarmmotionforadded
resistance.(B)Thebackrollingagymballdownthewall,superimposing
antagonisticarmmotiontodevelopcoordination.

Figure20.32.Partiallungewithcaneassistancetodevelopbalanceandcontrolfor
loweringbodyweight.

Figure23.31.(A)Deepforwardlungewhilelightlytouchingastablesurfacefor
balance(B)multidirectionallungesonastarpatternonthefloorand(C)deep
laterallungeagainstelasticresistance.

Figure23.62.Tuckjump.

StressManagement/Relaxation
Acomponentoftheeducationalprocessistoteachtheindividualhowtorelaxtensemusclesand
relieveposturalstress.Musclerelaxationtechniquescanbeincorporatedthroughoutthedayto
relieveposturalstress,andconsciousrelaxationtrainingincreasespatientawarenessandcontrol
overtensioninthemuscles.
Precaution:Thesetechniquesarenotappropriateformanagingacutepainduetoinflammation,
jointswelling,ordiscderangements.Ifthepatientisrecoveringfromapathologicconditioninthe
spine,cautionhimorherthatthesetechniquesshouldnotincreasesymptoms(otherthana
stretchingsensationinchronicconditions),especiallyradicularsymptoms.Cautionshouldalsobe
usedwithflexioninpatientswithamedicaldiagnosisofherniateddiscsothatsymptomsshouldnot
peripheralize.
MuscleRelaxationTechniques
Wheneverdiscomfortdevelopsfrommaintainingaconstantpostureorfromsustainingmuscle

contractionsforaperiodoftime,activeROMintheoppositedirectionaidsintakingstressoff
supportingstructures,promotingcirculation,andmaintainingflexibility.Allmotionsareperformed
slowly,throughthefullrange,withthepatientpayingparticularattentiontothefeelofthemuscles.
Repeateachmotionseveraltimes.Suggesttothepatientthattheseareminirestbreaksormicro
breakstobedoneatwork,home,orwhenevertension,stress,orposturalpainisexperienced.

CervicalandUpperThoracicRegion
Patientpositionandprocedure:Sittingwiththearmsrestingcomfortablyonthelap,orstanding.
Instructthepatientto:
Bendtheneckforwardandbackward.(Backwardbendingiscontraindicatedwithsymptomsofnerve
rootcompression.)
Sidebendtheheadineachdirectionthenrotatetheheadineachdirection.
Rolltheshouldersprotract,elevate,retract,andthenrelaxthescapulae(inapositionofgood
posture).
Circlethearms(shouldercircumduction).Thisisaccomplishedwiththeelbowsflexedorextended,
usingeithersmallorlargecircularmotionswiththearmspointingeitherforwardorouttotheside.
Bothclockwiseandcounterclockwisemotionsshouldbeperformed,butconcludethecircumduction
bygoingforward,up,around,andthenback,sothescapulaeendupinaretractedposition.Thishas
thebenefitofhelpingretrainproperposture.
LowerThoracicandLumbarRegion
Patientpositionandprocedure:Sittingorstanding.Ifstanding,thefeetshouldbeshoulderwidth
apartwiththekneesslightlybent.Havethepatientplacethehandsatthewaistwiththefingers
pointingbackward.Instructthepatientto:
Extendthelumbarspinebyleaningthetrunkbackward(seeFig.16.9B).Thisisparticularly
beneficialwhenthepersonmustsitorstandinaforwardbentpositionforprolongedperiods.
Flexthelumbarspinebycontractingtheabdominalmuscles,causingaposteriorpelvictiltorbend
thetrunkforwardwhilesitting,danglingthearmstowardthefloor.Thismotionisbeneficialwhenthe
personstandsinalordoticorswaybackpostureforprolongedperiods.
Sidebendineachdirection.
Rotatethetrunkbyturningineachdirectionwhilekeepingthepelvisfacingforward.
Standupandwalkaroundatfrequentintervalswhensittingforextendedperiods.
ConsciousRelaxationTrainingfortheCervicalRegion
Specifictechniquesinguidedimageryforthecervicalregiondevelopthepatient'skinesthetic
awarenessofatensedorrelaxedmuscleandhowconsciouslytoreducetensioninthemuscle.In
addition,ifdonewithposturetrainingtechniquesinmind,asdescribedearlierinthechapter,the
patientcanbehelpedtorecognizedecreasedmusculartensionwhentheheadisproperlybalanced
andthecervicalspineisalignedinmidposition.
Patientpositionandprocedure:Sittingcomfortablywitharmsrelaxed,suchasrestingonapillow
placedonthelaptheeyesareclosed.Positionyourselfnexttothepatienttousetactilecuesonthe
musclesandhelppositiontheheadasnecessary.Havethepatientperformthefollowingactivitiesin
sequence.
Usediaphragmaticbreathingandbreatheinslowlyanddeeplythroughthenose,allowingthe
abdomentorelaxandexpandthenrelaxandallowtheairtobeexpiredthroughtherelaxedopen
mouth.Thisbreathingisreinforcedaftereachofthefollowingactivities.
Next,relaxthejaw.Thetonguerestsgentlyonthehardpalatebehindthefrontteethwiththejaw
slightlyopen.Ifthepatienthastroublerelaxingthejaw,havehimorherclickthetongueandallow
thejawtodrop.Practiceuntilthepatientfeelsthejawrelaxandthetonguerestsbehindthefront

teeth.Followwithrelaxedbreathing.
Slowlyflextheneck.Asthepatientdoesso,directtheattentiontotheposteriorcervicalmusclesand
thesensationofhowthemusclesfeel.Useverbalcuessuchas,"Noticethefeelingofincreased
tensioninyourmusclesasyourheaddropsforward."
Thenslowlyraisetheheadtoneutral,inhaleslowly,andrelax.Helpthepatientpositionthehead
properlyandsuggestthatheorshenotehowthemusclescontracttoliftthehead,thenrelaxonce
theheadisbalanced.
Repeatthemotionagain,directthepatient'sattentiontothefeelingofcontractionandrelaxationin
themusclesasheorshemoves.Imagerycanbeusedwiththebreathingsuchas"fillyourheadwith
airandfeelitliftoffyourshouldersasyoubreatheinandrelax."
Thengothroughonlypartoftherange,notinghowthemusclesfeel.
Next,justthinkoflettingtheheaddropforwardandthentighteningthemuscles(setting)thenthink
ofbringingtheheadbackandrelaxing.Reinforcetothepatienttheabilitytoinfluencethefeelingof
contractionandrelaxationinthemuscles.
Finally,justthinkoftensingthemusclesandrelaxing,lettingthetensiongooutofthemuscleseven
more.Pointoutthatheorshefeelsevengreaterrelaxation.Oncethepatientlearnstoperceive
tensioninmuscles,heorshecanthenconsciouslythinkofrelaxingthemuscles.Emphasizethefact
thatthepositionoftheheadalsoinfluencesmuscletension.Havethepatientassumevarioushead
posturesandthencorrectthemuntilthefeelingisreinforced.
ModalitiesandMassage
Onceacutesymptomsareundercontrol,theuseofmodalitiesandmassageareminimizedor
decreasedsothepatientlearnsselfmanagementthroughexercises,relaxation,andposture
retraininganddoesnotbecomedependentonexternalapplicationsofinterventionsforcomfort.
Figure16.9.CervicalRotationandSidebendingUpglideManipulationsupine

HealthyExerciseHabits
Itisimportanttointegrateaprogressionofposturalcontrolintoallstabilizationexercises,aerobic
conditioning,andfunctionalactivities(seeChapter16).Thepatientiscarefullyobservedasgreater
challengestoactivitiesareperformedandifnecessary,remindersareprovidedtofindtheneutral
spinalpositionandtoinitiatecontractionofthestabilizingmusclespriortotheactivity.Forexample,
whenreachingoverhead,thepatientlearnstocontracttheabdominalmusclestomaintainaneutral
spinepositionandnotallowthespinetoextendintoapainfulorunstablerange.Thisisincorporated
intobodymechanics,suchaswhengoingfrompickingupandliftingtoplacinganobjectonahigh
shelf,orintosportactivitieswhenreachinguptoblockorthrowaball.Oncedevelopedunderyour
guidance,encouragethepatienttocontinuewithahealthylifestyle,fitnesslevel,andbody
mechanics.

IndependentLearningActivities
CriticalThinkingandDiscussion
1.Whatarethefunctionaldifferencesbetweenthewaythecervicalspineandlumbarspineareusedin
dailyactivities?
2.Explainhowfaultyposturecancausepainfulsymptoms.
3.Explainwhya"onesizefitsall"exerciseprogramforposturecorrectioncannotbenefiteveryone,or

howitmaybedetrimentaltosomeindividuals.Discussthisinrelationtoeachofthefaultypostures
describedinthischapter.
LaboratoryPractice
1.Practiceidentifyingtheeffectsvariouspostureshaveonthevariousregionsofthespinethatis,
whathappenstothecervicalandlumbarspinewheninsupine,prone,sidelying,sitting,and
standingposturesdoesthespinetendtomoveintoflexionorextension?Determinewhatisneeded
tochangethepositionthatis,ifflexionisemphasizedinaparticularposture,whatisneededto
movethespineintoamoreneutral(midrange)position?
2.Identifyandfeelwhathappenstothevariousportionsofthespinewhenmovingfromoneposition
toanother(i.e.,rollingsupinetoproneandreturn,movingfromsupinetosit,sittostandand
reverse).Whathappenstothelumbarspineandpelviswhenwalkinghowisthisaffectedifthe
personhasahipflexioncontracture,oracontractureintheexternalrotatorsofthehip?
3.ExaminethestandingpostureofaclassmatethenexaminethejointROM,muscleflexibility,and
musclestrength.Identifyanymuscleimbalancesinlengthandstrengththendesignanintervention
programtoinfluencechangeintheimpairments.Usetheguidelinespresentedinthischapterand
summarizedinBox14.1aswellasChapters16through22forsuggestedexercisesandtheirsafe
application.
4.Identifyandcomparethesimilaritiesanddifferencesinflexibilityandmuscleweaknessbetweena
personwithexcessivelumbarlordosisandananteriorpelvictiltandapersonwithaslouched
posturewhostandswiththepelvisshiftedforwardandthethoraxflexed.Whateffectdoeseach
pelvicposturehaveonthehipposition,andwhatmuscleswoulddeveloprestrictedmobility?Usually
intheslouchedposturethethoraxandupperlumbarspineareflexedwouldthecurlupexercisebe
beneficial,orwoulditcontributetothisproblem?Developanexerciseprogramthataddressesthe
commonflexibilityandstrengthimpairmentswithoutreinforcingthefaultyposture.
CaseStudies
Case1
Yourpatientisa35yearoldcomputerprogrammerwhoisreferredtoyoubecauseofpain
symptomsintherightcervical,posteriorshoulder,andarmregions.Thesymptomsgetprogressively
worsewhenatworkusuallythepainbeginswithin1hour,anditis6/10bylunchtime.Thesame
cycleoccursintheafternoon.Thereisoccasional"tingling"inthethumbandindexfinger.The
symptomshaveprogressivelyworsenedoverthelast3months,eversincebeingplacedinapriority
job.Recreationalactivitiesincludetennisandreadingthetennisdoesnotcausesymptoms,but
readingmakestheneckpainworse.
Examinationrevealsforwardheadandroundshoulderposture.Capitalflexion50%range,cervical
rotationandsidebendingareeach80%range,shoulderexternalrotationis75.Thereisrestricted
flexibilityinthepectoralismajor,pectoralisminor,levatorscapulae,andscalenemuscles.Cervical
quadranttestreproducesthetinglingintherighthandallotherneurologicaltestsarenegative.
Strengthofthesuprahyoidandinfrahyoidmuscles,scapularretractors,andshoulderlateralrotators
is4/5.
Whatisprovokingthepatient'ssymptomsandsigns?Whatarethefunctionallimitations?Whatisthe
prognosis?
Identifyimpairmentandfunctionaloutcomegoals.
Establishaprogramofintervention.Howcanyouprogressthispersontofunctionalindependence?
Case2
A51yearoldautomechanicisreferredtophysicaltherapybecauseofpainsymptomsintheleft
buttockandposteriorthigh.Thesymptomsareworsewhenstandingandreachingoverheadformore
than15minutes,whichiswhathedoeswhenworkingonacarthatisupontheracks.Carrying
heavyobjects(>50lb),standing,andwalkingformorethanahalfhourincreasethesymptoms.
Thereisnoprecipitatingincident,butthesymptomshavebeenrecurrentoverthepastyear.

Symptomsalsoincreasewiththerecreationalactivityofbackpacking.Symptomseasewheninthe
rockerrecliner,lyingonacouchwithkneesbent,orwhenhuggingkneestochest.
Examinationrevealsswaybackposturewhenstandingdecreasedflexibilityinthelowback,gluteus
maximus,hamstrings(straightlegraisingto60),andupperabdominalsandincreasedpainwith
backwardbending.Strengthofthelowerabdominalsis3/5.Heisabletodorepetitivelungesand
partialsquatsforamaximumof20seconds.
Whatisprovokingthepatient'ssymptomsandsigns?Whatarethefunctionallimitations?Whatisthe
prognosis?
Identifyimpairmentandfunctionaloutcomegoals.
Establishaprogramofintervention.UsethetaxonomyofmotortasksdiscussedinChapter1(see
Figs.1.6and1.7andaccompanyingtext)todevelopaprogressionofexercisesandtasksto
progressthispersontofunctionalindependence.
Figure1.6.Manualresistanceexercise,aproceduralintervention,isaformof
therapeuticexerciseusedduringtheearlystageofrehabilitationifmusclestrength
orenduranceisimpaired.

Figure1.7.Taskspecificstrengtheningexercisesarecarriedoutbyliftingand
loweringaweightedcrateinpreparationforfunctionaltasksathomeorwork.

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Copyright:
Copyright2012byF.A.DavisCompany.Allrightsreserved.
DatabaseTitle:
STAT!RefOnlineElectronicMedicalLibrary
Editor:
CarolynKisnerPT,MS
LynnAllenColbyPT,MS
ISBN:
ISBN10:080362574X
ISBN13:9780803625747
PublicationCity:
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PublicationYear:
2012
Publisher:
F.A.DavisCompany
Title:
TherapeuticExercise:FoundationsandTechniques6thEd.(2012)
DatePosted:
9/26/20158:19:18AMCDT(UTC05:00)
DateAccessed:
5/11/20166:42:20AMCDT(UTC05:00)
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THERAPEUTICEXERCISE:FOUNDATIONSANDTECHNIQUES6thEd.(2012)
PartIVExerciseInterventionsbyBodyRegion
Chapter14.TheSpine:Structure,Function,andPosture
Introduction