DR.

ABDUL RASHAD
SENIOR LECTURER
DPT,MPHILL(OPT) ,MPPTA, MMTC
(NZ), MSTC(AUS), SIR(AUS),
IASTM(GREECE)
UNITED COLLEGE OF PHYSICAL
THERAPY
Session Objectives…

Learn how to build a functionally strong body for both daily

living and peak performance.
1. Define posture.
2. Learn about the factors that can influence
postural alignment.
3. Discover how to assess and analyze static and
dynamic posture within scope of practice.
4. Identify common dysfunctional movement
patterns
5. Identify exercises that may help restore muscle
balance and correct posture.
 Posture….who cares!!??!!
• Performing involves 3 factors :
– How you Look
– How you Sound
– How You Act
• The audiences’ perception of your performance is
influenced by the way you carry yourself…attitude
is everything!!… well,….almost……

THE GENERAL WAY OF HOLDING THE BODY

• Birth
– Entire spine concave forward
(flexed)
– “Primary curves”
• Thoracic spine
• Sacrum
• Developmental (usually
around 3 mos.)
– Secondary curves
– Cervical spine
– Lumbar spine
 Normal Postural Development
• Single C - curve at birth
• 4 to 5 months Cervical curve
– When extensors of the neck and back
are strengthened by head lifting
• 12 to 16 months Lumbar curve
– When extensors of the lower back
are strengthened by walking
• Lordosis - week abs/tight hip
flexors
Normal Spine Curvature
Posterior (Back)
Spinal Column
Posture:
• The position of your body parts
in relation to each other
Vertebral Alignment
– Counterbalancing anterior-posterior
curves
– Act as shock absorbers, reduce injury
• Postural Curves
– Primary curve: concave anteriorly (at
birth)
– Secondary curve: anteriorly convex
curves of cervical and lumbar regions
(develop during weight bearing)
• Pelvic position
– Should remain neutral
– ASIS and PSIS level in the transverse
plane
– ASIS and pubis symphysis are in same
vertical plane
 Benefits of “Neutral Spine”…
More specifically:
• Powerful movements depend on
every part of the spine being • Cervical spine gives your
strong. head freedom of movement,
• The spine coordinates whole • Thoracic allows rotation of
body power via proper execution your trunk,
of movements or exercises. • Lumbar spines provides
• Perfect posture pays share by stability,
reducing stress/loads which leads • Sacrum provides the base
to tension in the antigravity for your spine to sit on.
musculature, degeneration of • Sacroiliac joints act as a
weight bearing structures, less pivotal axes allowing
movement integration
efficient movement, misalignment between your legs, pelvis
and risk for injury. and spine.
Posture of Children
• Child development and flexibility allows for
momentary deviations that would be considered
faulty in adults.
– Foot generally flat until 6-7 years of age
– Hyperextension of knees common
– Knock-knee common until 6-7 years of age
POSTURE
• Posture is defined as
“a position or attitude of the body, the relative arrangement
of the body parts for a specific activity or characteristic
manner of bearing one’s body.”
• In general, posture is the position of your body parts in
relation to each other at any given time

• Ligaments, fascia, bones and joints are inert structures

that support the body, whereas muscles, tendonous
attachments are the dynamic structures that maintain the
body in a posture or move is one posture to another.
• Gravity plays an important role to maintain upright
posture of the body.

• Normally gravitational line goes through the physiologic

curves of the spinal column an they are balanced.

• If the weight in one region shifts away from the line of

gravity, the remainder of the column compensates the
regain equilibrium.
• For weight bearing joint to be stable, or in equilibrium,
the gravity line of the mass must fall exactly through the
axis of motion, or there must be a force to counteract the
force of gravity.

• In body, the counter force is either muscle or inner

structures.

• Upright posture, usually involves a slight anterior-

posterior swaying of the body of about 4 cm.
 Anti-gravity Muscles
• These muscles are the hip
and knee extensors, and the
trunk and neck extensors.
Other muscles, perhaps less
involved, but also important in
maintaining the upright
position, are the trunk and
neck flexors and lateral
benders, hip abductors and
adductors, and the ankle
pronators and supinators. If
all of these muscles were to
relax, the body would
collapse.
What is posture?

• Posture is the position in which you hold your body

upright against gravity while standing, sitting or lying
down.
• Good posture involves training your body to stand,
walk, sit and lie in positions where the least strain is
placed on supporting muscles and ligaments during
movement or weight-bearing activities.
• Correct posture
– “Position in which minimum
stress is placed on each
joint.” (Magee)
• Faulty posture
– Any position that increases
stress on joints
CORRECT POSTURE
“…that state of muscular and skeletal balance which protects the
supporting structures of the body against injury or progressive
deformity irrespective of the attitude (erect, lying, squatting, stooping)
in which these structures are working or resting. Under such
conditions the muscles will function most efficiently and the optimum
positions are afforded for the thoracic and abdominal organs.” (AAOS)

• Maximal biomechanical efficiency

• Minimal stress on ligaments and strain on muscles
PROPER POSTURE REQUIREMENT

1. Good muscle flexibility

2. Normal motion in the joints
3. Strong postural muscles
4. A balance of muscles on both sides of the spine
5. Awareness of your own posture, plus awareness of
proper posture which leads to conscious correction.
• With much practice, the correct posture for standing,
sitting, and lying down will gradually replace your old
posture.
• Posture is the position of
the body at a given point in
time
• Correct posture can:
– improve performance
– decrease abnormal stresses
– reduce the development of
pathological conditions
 What is
Good Posture?
Minimal stress on
the vertebral joints
and supporting
ligaments.

Body segments
balanced around
the center of gravity
POOR POSTURE

“…faulty relationship of the various parts of the body

which produces increased strain on the supporting
structures and in which there is less efficient balance
of the body over its base of support.” (AAOS)

• Increased strain on body and less efficient

• Cause of various physiological and anatomical
impairments
 Poor Posture

• One of the first indicators of poor posture

is a slouching or forward head posture.
• This posture closes down on lymphatic
drainage in the neck and will cause more
strain on the posterior neck muscles.
• It also increases the weight bearing on the
discs and can lead to premature arthritis of
the neck.
• There are many causes of this type of
posture including car accidents, sports
injuries, working with computers and loss
of bone density.
 TYPES OF POSTURE

• STATIC POSTURE
• DYNAMIC POSTURE
 STATIC POSTURE

• Body and segments are maintained in

certain posture.

• Static posture control involves

maintenance of particular posture against
gravity. e.g lying or standing
 STATIC POSTURE
• For any stationary posture to be maintained,
two rules of equilibrium must be satisfied.
i. A vertical line, directly through the centre of
gravity of the body must fall within the body’s
base of support.
ii. The net torque (or moment) about each
articulation of the body must be zero.
(pheasant, 1991).
• The static posture is that of the body at rest;
although obviously the body is never
completely still, minute postural adjustments
are being made continually.
 DYNAMIC POSTURE

• This is the adopted while the body is in

action, or in the defensive phase just prior
to an action occurring.
 DYNAMIC POSTURE

• Body and body segments moving that is walking

and running, jumping, throwing and lifting.

• Dynamic posture involves maintenance of stability

during movements of the body.

• Human has the ability to arrange and to re-

arrange the body segments to form larger variety
of postures bilateral single leg erect standing,
sitting, lying down and kneeling, maintain erect
bipedal position is difficult.
• It allows person to use their upper extremities for
the performance of large and small tasks.

• Erect posture increases work of heart increases

stress on the vertebral column, pelvis and lower
extremities and reduces stability.

• Maintain the static erect posture requires very

little energy expenditure in the form of muscle
contraction.

• The bones, joints, ligaments are able to provide

the major torques needed counteract gravity, and
frequent changes in body position assist in
permitting circulatory return.
POSTURAL CONTROL
• Person’s ability to maintain stability of the body
segments in response to forces that threaten to
disturb the body’s structural equilibrium.

• Central Nervous System able to respond to all of

this input with appropriate output to maintain the
equilibrium of the body.

• Musculoskeletal system must have a range of

motion that is need for specific work. Muscle
must respond with appropriate speeds and
force.
• Central Nervous System receives and process
information from all system and must be interpret
information from the receptors regarding the
position of the body in the space.

• When inputs altered or absent in weightless

conditions during space light or decreased
sensation in the lower extremities the control
system must respond to incomplete or distorted
data thus person posture may be altered.
 Postural Control:
• Minimal amount of muscular activity required to
maintain stable, erect posture
– Control of posture is complex
• Static or dynamic
• Skill that CNS learns using information from biomechanical
elements and sensory systems.
– Reactive (compensatory control) – responses occur as
reactions to external forces that displace the body’s
COG
– Proactive (anticipatory control) – responses occur in
anticipation of internally generated destabilizing forces
• Raising arms, bending forward, etc.
• Goal of posture: control body orientation in space, maintain COG over
BOS, stabilize head with respect to vertical so that eye gaze is properly
oriented
 Postural control:
• Maintenance of posture depends on integrity of CNS, vision,
vestibular system, musculoskeletal systems.

• Muscle Synergies: Combinations of muscles work to

complete a task.
– CNS functions to choose most effective combinations
– Proprioception plays large role in choice
– Vestibular system governs overall force

• Perturbations: sudden change in conditions that displaces

body position away from equilibrium
– Sensory – alteration of visual cues
– Mechanical – changes in relationship of COG to BOS
– Can recover by moving segments or entire body
 Postural control:
• Ankle Strategy:
– Discrete bursts of muscle activity on anterior and/or posterior
aspect of ankle that occur in response to forward and backward
movements of COG
– Primarily responsible for maintenance of upright
– Muscles respond to restore COG within BOS
– If ankle response is not adequate, then use stepping strategy

• Forces working on the body:

– External forces are inertia, gravity, ground reaction forces
– Internal forces are produced by muscle tension, passive tension of
ligaments and soft-tissue structure.
• Control postural sway – 12 º in sagittal plane, 16º in frontal plane.
 POSTURAL ALIGNMENT
• Good posture requires the alignment of the
different weight bearing segments of the body
upon each other.
• Center of Gravity: imaginary point
representing the weight center of an object

• Line of Gravity: imaginary vertical line

that passes through the center of gravity
 Correct Posture (Lateral)
Line is…
• Through external
auditory meatus
(Ear)
• Midway through
shoulder
• Through lumbar
bodies
• Slightly anterior to
midline of knee
• Slightly anterior to
lateral malleolus
IDEAL POSITION OF THE BODY
• Kendall et al(1952), Joseph (1960),
Woodhull et al (1985), there is general
agreement that:
• In standing, the centre of gravity of the
body lies at 55-57% of the height of the
person above the ground or approximately
the level of the vertebral body of S2.
 ANKLE
• The centre of gravity falls in front of the ankle joint
approximately midway between the heel and the
metatarsal heads, tending to rotate the tibia forwards
about the ankle.
• This is resisted by the plantar flexors, especially soleus.
 KNEE
• The normal line of gravity runs anterior to the knee joint,
keeping it in extension.
• Stability is provided by the anterior cruciate ligament,
and tension in the Gasrocnemius and hamstrings.
• If the knee joint in full extension, active muscle work is
not necessary, but if the knee flex, then quadriceps must
work concentrically to maintain an upright stance.
 HIP
• The line of gravity usually lies approximately 1.8 cm
behind the hip joint, but this varies with the body’s sway.
• In this position posterior rotation of the pelvis is
controlled by tension in the hip flexor iliopsoas and
ligamentous stability from the iliofemoral ligament.
• If the line gravity is directly through the hip joint, there is
equilibrium ; if it falls anteriorly, it is stabilized by the hip
extensors.
 TRUNK
• The line of gravity usually falls through the bodies of the
vertebrae of the cervical and lumbar regions and though
the physiological curves of the spinal column in such a
way that the spine is balanced.
 HEAD
• The line of gravity is anterior to the atlanto-occipital
joints, tending to rotate the head forwards on the
vertebral column.
• This balanced by activity of the posterior cervical
muscles.
 NORMAL POSTURE
STANDING
Lateral View (Plumb Line)
HEAD Through the ear lobe

SHOULDER Through tip of the acromion process

THORACIC Anterior to the vertebral bodied

LUMBAR Posterior to the vertebral bodies

PELVIS Level with an anterior or posterior tilt

HIP Through the greater tuberosity slightly posterior to the hip joint
axis
KNEE Slightly posterior to patella anterior to the knee joint knee
extension
ANKLE Slightly anterior to the lateral malleolus with ankle joint in
neutral position
Ideal posture: • Ideal Standing Posture:
– Lateral Position: vertical line
passes through the following
– Head: through ear lobe
– Shoulder: tip of acromion
process
– Thoracic spine: anterior to
vertebral bodies
– Lumbar spine: through
vertebral bodies
– Pelvis: level with ant-posterior
tilt
– Hip: through greater trochanter
– Knee: slightly posterior to
patella
– Ankle: slightly anterior to the
lateral malleolus with ankle in
neutral position
 Anterior view
HEAD Extended and level

SHOULDER Level and not elevated or depressed

THORACIC Centered in midline

LUMBAR Centered in midline

PELVIS Level with both ASIS in the same plane

HIP Slightly apart

KNEE Level and not bowed or knock

ANKLE Normal arch in feet Slight outward toeing

 Posterior view
HEAD
Extended and not flexed or hyperextended
SHOULDER
Level and not elevated or depressed
THORACIC
Centered in midline
LUMBAR
Centered in midline
PELVIS
Level with both PSIS in the same plane
HIP
Slightly apart
KNEE
Level and not bowed or knock
ANKLE
Calcaneous should be straight
For Anterior Photograph
Client faces the camera. The bold
center, vertical line should line up
with the center of the body. Line
bisects head, neck, trunk, hips and
medial malleoli. Vertical alignment
line goes from the nose, chin, center
of the chest, navel and between the
medial malleolus. Horizontal
alignment lines provide reference for
the level of the eyes, ears, shoulders,
hands, pelvis, and knees.
For Lateral Photograph Client
faces sideways. Photograph right
and left view. Bold center grid line
directly behind and slightly
anterior of the lateral malleolus.
Look for line extending from ear to
acromial process through greater
trochanter of femur, slightly behind
patella and one inch anterior to
lateral malleolus. Bisecting
vertically through these areas.
For Posterior Photograph
Client faces grid. The bold
center, vertical line should line
up with the center of the body.
Vertical alignment line bisects
head, through neck, vertebrae,
buttocks and medial malleoli.
Horizontal alignment lines
provide reference for the level of
the ears, shoulders, hands,
pelvis, and ankles.
Anterior View
Head lateral flexed to right.
Left shoulder higher. Arm
length difference. Rib cage
rotated. Legs turned out.
Right foot supinated. Left
foot pronated.
• Posterior View
Left elevated shoulder.
Pronated left foot. Knock
knees. Palms face
posterior.
• Right Lateral View
Chin lifted, back of
neck shortened.
Forearms anterior of
body.
Anterior pelvic tilt.
• Left Lateral View
Forward Head. Upper
back rounded. Tight
lumbar spine and hip
flexors. Body forward.
POSTURAL SWAY
• POSTURAL SWAY the phenomenon of constant
displacement and correction of the position of the center
of gravity within the base of support.
OR
• In standing there is continuous movement due to
alternating action of antagonist muscle groups resisting
gravitational stresses, endeavoring to keep the total
centre of gravity of the body within the body’s base of
support. This results in slight antero-posterior swaying
of the body of app. 4cm excursion.

• Postural sway varies across the life spans, being

greatest in young and elderly (Woollacott, 1990)
 Posture:
• Static and dynamic posture depend on
muscular contraction of “antigravity”
muscles
• Primarily hip & knee extensors, trunk
& neck extensors
• Secondarily, trunk & neck flexors, hip
ab/adductors, ankle pronators &
supinators
• If these muscles were to completely
relax, the body would collapse
• Postural Sway controlled by
ankle plantar and dorsiflexors,
controlling anterior-posterior
motion
– Constant displacement and
correction of the COG within
BOS
• Postural sway will be increase if:
• The eyes are close.
• The base of support narrow.

• Propriocepture influences from foot &

ankle (Romberg, 1890)
• Evaluation of postural sway
By Force Platforms.
– Used to evaluate steadiness
CHANGES OF POSTURE
STANDING UPRIGHT
• Physiologically efficient
• Balance is dynamic
• Energy expenditure necessary to maintain such
position is negligible
• In upright standing the vertebral column shows its
characteristics alternating curves shapes with:
– Primary kyphotic curves, convex to the rear in the
thoracic and sacral areas.
– Secondary lordotic curves, concave to the rear in
the cervical and lumber areas.
• In Standing
– The anterior superior iliac spine and pubic
symphysis are vertical.
– The sacrum inclined forward at an angle
approximately 50 degrees to the horizontal.

• In Standing, there is variation in the sacral

angle b/w individuals and this has an effect on
lumber spine.
• If the sacral angle is increased them the lumbar
spine will have to assume an increased lordosis to
compensate and maintain an erect posture.
• If the sacral angle is small, the lordosis will be
flattened
• Although there may be much variation in the
degree of:
• Lumber lordosis
• Pelvic tilt
• Lateral curvature (scoliosis), all may fall within
what would be considered normal upright
posture.
• However, when these becomes extreme they
may be lead to characteristics postural
dysfunction patterns.
SITTING POSTURE
• One of the most frequency
adapted, particularly in the work
place.
• Sitting necessitates app.
• 90 degree flexion of knees and
hips
• To bring the trunks forward
over the thighs.
Sitting Posture
– Great deal of stress on
intervertebral disk
– Greater pressure as you
lean forward.
– Lumbar curve is
decreased and pressure
increases
– Increased & sustained
muscle contraction
required to keep body
upright
• It becomes tiring and uncomfortable to maintain this
upright seated position if no support is available from
the chair.
• The individual will assume a slouched position
ligaments and the pressure at the intradiscal interface.
• Disc pressures are app. 40% greater when sitting
than when standing.
• Greater when the lumber curve is flattened than
when the lordosis is maintained.
• Disc pressure varied with the effect of seat
angle and the increasing the seat angle i.e. the
angle b/w the legs and the trunk, up to 130O
decreases the pressure at the Disc.
• A person leaning back at an angle of 110-120
degrees, with a lumber support, disc lead will
result that are 30-40% lower than that of
standing posture. This position also produced
lower muscle stress as measured by EMG.
• In clinical sitting, use of lumber support in a
chair is Recommended as it helps to restore a
lumber lordosis without requiring muscles effort
and keeps the beck in a support position. (by
Andreson and Ortengren, 1974)
Lying posture
• A position complete comfort and relaxation
• The position may be varied.
• Supine
• Prone
• Side lying
• it is the least energy consuming position, as the COG is
low and GF are resisted by passive mechanism.
• Lying prone accentuates the lumber lordosis, while
supine lying reduces the lordosis, or may produce a
kyphotic lumber spine, depending on the amount of
support given to the spine by the surface that is being
laid upon.
• Disc pressure in supine lying is 35% of that of
standing.
• In side lying it is 75% of that of standing
because of the side flexion of the spine that
occurs in such a position.
• the spine should remain as neutral as possible,
so the head should be supported on pillow to
maintain a symmetrical neutral alignment of
the head on the spine irrespective of which
lying position is adapted.
Factors Affect Posture
There are some factors
contribute to bad
posture as:
• OBESITY
• PREGNANCY
• MUSCLE WEAKNESS.
• USE HIGH-HEELED SHOES.
• BACK PACK
• Experts say that one should carry a
backpack weighing up to 15% of your
body weight and never more than 20%
(Washington Post, September 14, 1999).
•The following are the recommended limits set forth by the ACA ( American
Chiropractic Association), the APTA (American Physical Therapy Association),
and the AAOS (American Academy of Orthopedic Surgeons):

Person's Weight (lb) Maximum Backpack

Weight (lb)
60 5
60-75 10
100 15
125 18
150 20
200 or more 25*
*No one should carry more than 25 lb.
Factors Affect Posture

• Shortening of muscles.

• Decrease flexibility and

ignorance of good posture.
 Factors that influence Posture…
• Aging- your body gradually loses its capacity to absorb and transfer
forces however its not aging that influences posture as does:
• Inactivity/sedentary living/reluctance to exercise -leads to loss of
natural movement flow,
• Poor postural habits -eventually becomes your structure,
• Biomechanical compensation → muscle imbalance, adaptive
shortening, muscle weakness & instability,
• Body composition – increases load, stresses on spinal structure,
leads to spinal deviation,
• Workspace –ergonomics,
• Poor movement technique/execution/training ,
• Injury -leads to reduced loading capacity or elasticity,
• Others:
*Posture is the single most common cause of painful soft tissue
syndromes affecting the body!
Causes of Poor posture
Structural Causes
– Structural factors
• Congential anomalies
• Developmental problems
• Trauma
• Disease
• Permanent anatomical deformities not amenable to correction by
conservative treatments
Positional Causes
• Poor postural habit--for whatever reason, the individual does not
maintain a correct posture
• Psychological factors, especially self-esteem.
• Respiratory conditions
• General weakness
• Loss of the ability to perceive the position of your body
Causes of Poor Posture
• Heredity

• Poor fitness (muscle

strength & endurance)

• Environmental
Influences (work
environment)

• Bad Habits/ Body

Mechanics
CHARACTERISTIC OF POOR POSTURE

• Described by the Kisner & Colby, 1990.

• Poor posture occurs when there is a faulty relationship
b/w different body parts, resulting stress on body
structures.
POSTURAL FAULTS
• Postural pain syndromes
• Postural dysfunctions
• Poor postural habits
POSTURAL PAIN SYNDROMES
• These occurs when postural deviations from normal
alignment but has no structural limitation.

• Postural pain results from mechanical stress but will

be relieved by activity or a change of posture.

• No abnormalities exist in muscular strength,

flexibility or balance, but continued failure to a
adapted a correct posture may lead to their
development. e.g working on a car engine- leaning
under the bonnet.
POSTURAL DYSFUNCTIONS
• There is shortening of soft tissue and muscle
weakness, either due to poor posture habits or
trauma to the soft tissues.
• Stress on the shortened structures causes
pain, and imbalances in muscle strength and
flexibility may result in further stresses to the
area.
• e.g the dominant side of someone who plays a
lot of racket sports.
POOR POSTURAL HABITS
• Especially in the developing child, may
lead to adaptive changes in muscles
and soft tissues and abnormal stresses
on growing bone.
CHARACTERISTIC OF POSTURAL
ABNORMALITES

• describe by kendall et al, 1952 in the classic work

posture & pain & by kisner & colby.

1. relaxed or swayback posture

2. hyper lordotic posture
3. flat back posture
4. scoliosis
5. increased kyphosis (dowager’s hump)
6. flat upper back
7. forward head
8. flat neck
HYPER LORDOTIC POSTURE
• There is increased in lumbo-sacral angle, producing an
increased lumbar lordosis, increased anterior tilt the
pelvis and hip flexion.

• There is often compensatory increase to the thoracic

kyphosis.(this is termed “Kypholordosis”)

• It is often slack gluteal and abdominal muscles.

• The commonest causes are:

– Pregnancy
– Obesity
– Weakness of abdominal musculature
– Sustained poor posture
• Lordosis causes:
• Postural deformity
• Lax muscles (esp.
abs)
• Heavy abdomen
• Compensatory
mechanisms
• Hip flexion contracture
• Spondylolisthesis
• Congential problems
• Fashion (high heels)
• Lordosis
– Swayback deformity
• Increased pelvic
inclination (40)
• Typically includes
kyphosis
Alignment May be May be Exercises
tight weak
Anterior tilt Hip flexors Abdominals Stretch hip flexors
Strengthen obliques for
stabilization
Avoid full sit ups

Hip flexion Hip extensors Strengthen

gluteals

Extreme low back Low back Stretch low

extension extensors back extensors
(hyperextension)
FLAT BACK POSTURE
• There is decreased lumbo-sacral angle,
decreased lumbar lordosis and a
posterior tilting of the pelvis.
• The commonest causes are:
• Long term slouching
• Maintenance of flexed postures.
INCREASED KYPHOSIS (DOWAGER’S HUMP)

• There is an increase in the thoracic kyphosis, round

shoulders through protraction of the scapulae and
forward position to the head, leading to POKING CHIN
and compensatory cervical lordosis.
• It is caused by :
• Relaxation of the muscles necessary to counteract
gravity.
• Slouching and sustained flexed postures.
• It may cause pain due to abnormal muscle stresses and
decreasing the space for nerves to travel, as in thoracic
outlet syndromes.
• Kyphosis
– Excessive posterior
curvature of the spine
• Round back
• Flat back
• Dowager’s Hump
Kypho-lordotic Posture
• Many people do not have an ideal posture. There are
four types of postural alignment that deviate from the
ideal alignment, which we often encounter. They are
known as: ‘Kyphosis’, ‘Lordosis’, ‘Sway back’ and ‘Flat
back’.
• Kyphosis
• Kyphosis is usually associated with an increase curve of
the thoracic spine. Along with this, a slightly posterior
pelvic tilt is seen along with a reduced lumber curve and
a forward head position. The client will show a hunched
over posture with a depressed chest.
• Lordosis
• We speak of Lordosis when there is an increased curve
in the lumbar spine of lower back. Often there is also an
increased pelvic tilt. The client will show a posture in
which the stomach and head are pushed forward.
FLAT UPPER BACK
• There is decrease in the thoracic kyphosis, depression
of the scapulae and clavicles and flat neck position.
(loss of cervical lordosis).

• It is close to an exaggerated Military posture.

• This may lead to pain due to fatigue of antigravity

muscles working to maintain such a posture and
muscle imbalance.
Alignment May be May be Exercises
tight weak
Posterior Pelvic Hamstrings Stretch
tilt hamstrings

Low back Back extensors Strengthen back

flexion extensors

Hip extension Hip flexors Strengthen hip

flexors
• A Flat back is when very little or no lumbar curve
is present. There will pretty much always be a
posterior pelvic tilt of in a neutral position.
Flat Back
 FORWARD HEAD
• At the cervical area there is increased flexion of the
lower cervical and upper thoracic regions and
increased extension of the upper cervical vertebrae
and occiput on the First cervical vertebra.

• Problems may arise due to stress of anterior or

posterior longitudinal ligaments, muscle tension and
fatigue or impingement of the cervical plexus.

• It is commonly caused by occupational working

postures that require forward leaning or due to muscle
weakness and fatigue.
• e.g computing
Head forward posture:

• Common
compensation in the
elderly
• Dowager’s hump
• Can also lead to TMJ
problems
FLAT NECK
• There is decreased cervical
lordosis with increased flexion of
the occiput on the atlas.
• It is often seen with exaggerated
Military posture.
• It is characterized by an increased
curve in the lumbar spine of lower
back and an anterior pelvic tilt.
The client shows a posture in which
the chest is pushed forward.
Scoliosis
Lateral curvature of spine

• This condition of side-to-

side spinal curves is
called scoliosis. On an X-
ray, the spine of an
individual with scoliosis
looks more like an "S" or
a "C" than a straight line.
Some of the bones in a
scoliotic spine also may
have rotated slightly,
making the person's waist
or shoulders appear
uneven.
 SCOLIOSIS
• Types of scoliosis:

✓ Physiological
✓ Idiopathic
✓ Juvenile
✓ Pathological
• Most backs have some degrees of slight lateral
curvature.
• The main part of the curve tends to be concave to
the dominant side and there may be compensatory
curves above and below.
• The cause may be due to
– Leg length inequality
– Asymmetry of the pelvis
Scoliosis Examination Summary
• Physical assessment
• Cardiopulmonary
• Adam’s Forward Bending
Test
• Leg length
• Plumb line
• Range of motion
• Palpation
• Neurological assessment
• Physical assessment-check for asymmetry of shoulders or hips,
humpback
• Cardiopulmonary- Testing of the function of the heart and
lungs.
• Adam’s Forward Bending Test-The patient bends forward at the
waist, with arms extended forward. The physician looks for
asymmetry thoracic prominence (such as a shoulder blade), or
a lumbar prominence.
• Leg length-Both legs are measured to determine if they are of
equal length.
• Plumb line- Put plumb line along sagittal plane and check for
assymetry
• Range of motion-Test the patients ability to perform flexion,
extension, bending, and rotation movements.
• Palpation-The physician "feels" for abnormalities.
• Neurological assessment – Identify the patient’s symptoms
such as pain n, numbness, tingling, extremity weakness or
sensation, muscle spasm, and bowel/bladder changes.
Scoliosis
Curve in Degrees Treatment
0-20 Observe for progression

20-25 Brace if progression documented, and

substantial growth remaining

25-30 Brace if progressive and growth remains

30-40 Brace if growth remains

40-45 Brace if growth remains vs. Surgery

> 45- 50 Surgery

CAUSES OF POSTURAL PROBLEMS
Lee- Jones (1988), causative factors
categories:
➢Genetic
➢Environmental.
➢Psychosocial
➢Physiological
➢Idiopathic
GENETIC FACTORS
• Gender
• Body type
• Congenital birth defects
• Intrinsic disability and diseases
• Joint flexibility
ENVIRONMENTAL FACTORS
• Nutrition
• Trauma, postural strain
• Extrinsic disability and diseases
• Aging
• Clothing
• Physical adaptation
• Occupation
• Physical exercise
PSYCHOSOCIAL FACTORS
• Self esteem
• Body image
• Mental health
• Learned postural habits
• Lifestyle
PHYSIOLOGICAL FACTORS
• Age
• Growth
• Pregnancy
• Physiological processes
• Fatigue
• Body weight
• Tissue degeneration
• Muscle tension
• Flexibility
• Pain
IDIOPATHIC FACTORS
• Paralysis
• Bone malformation
• Vestibular system function
• In some categories it will be easier to influence change
than in others.
• PHELPS et al, 1956 stated that,
• “Environmental circumstances are among the chief
influences in producing man’s postural dysfunctions.”
• Many patients will show combined causal factors rather
than simple cause effect relationship. e.g in age related
O.A of the joints the following conditions may combine
to give a patient poor postural health.
• Poor nutrition
• Low self esteem
• Post menopausal osteoprosis
• Poor postural habits
• PT may identify the relationship b/w different causative
factors of faulty posture and manipulate them to try to
achieve efficient intervention strategies to regain
postural health for the patient.
• History of injury?
• Any previous back or neck pain?
• Any positions of comfort?
• Family history?
• Previous illnesses, surgeries, or severe injuries?
• Hx of other conditions (connective tissue diseases such
as Marfan’s Syndrome)?
• Footwear?
• Patient age?
• Growth spurt?
• In females, related to menarche/menses?
• Deformity progressive or stationary?
• Neurologic symptoms?
• Nature, extent, type, and duration of pain?
• Exacerbating activities or positions?
• Difficulty breathing?
• Previous treatment? Did it help?
• Body type
• Ectomorph
• Mesomorph
• Endomorph
ASSESSMENT

• Observations
– General postural
 • Malleoli level
• Arches
• Foot rotation
• Anterior view
• Bowing of bones
• Head straight on
shoulders • Diastematomyelia (hairy
patches)
• Shoulders level
• Pigmented lesions
• Clavicles/AC joints • Café au lait spots
• Sternum & ribs • neurofibromatosis
• Waist angles & arm
positions
• Carrying angles
• Iliac crests
• ASIS
• Patellae
• Knees
• Fibular heads
EXAMMINATION AND MEASUREMENT OF
POSTURE

• It is important that the comfortable, erect posture

assumed by a patient on request at the time of
examination is representative of their true postural
alignment.
Postures Assessment
• Alignment
• Minimizing muscle imbalance
• Spinal column curves
– C 1-7 concave
– T 1-12 convex
– L 1-5 concave
– S 1-5 convex
• Analysis of muscle imbalance
– Questions:
• too tight?
• too loose?
• role of gravity?
Postural assessments include:
• Examination of the alignment when the
• subject is standing
• Tests for flexibility and muscles length
• Tests for muscle strength as well as palpation
techniques.
• But for our purposes we are only looking at the
assessment procedure while standing and then
expanding this to include sitting and lying down.
Postural assessment
• A formal postural assessment is done with a plumb line.
Whereby, the client is positioned with a plumb line
passing just in front of the lateral malleolus (coronal
plane). In an ideal posture, this line should pass just
anterior to the mid-line of the knee and then through the
greater trochanter, bodies of the lumbar vertebrae,
shoulder joint, bodies of the cervical vertebrae and the
lobe of the ear
• Next the subject is then viewed from the front (sagittal
plane), with the feet about seven cms (7 cm)apart (three
inches), the line should bisect the body into two equal
halves. The anterior superior iliac spines (ASIS) should
be approximately in the same horizontal plane, and the
pubis and ASIS should be in the same vertical plane
• In conjunction with the sagittal and coronal plane
assessments, it also follows to observe anatomical
landmarks, such as the lateral malleolus, patella
and acromion processes, as well as looking at the
muscular and structural differences. Compare the right
and left sides of the body on a horizontal level and
observe any differences to the norm.
Questions and observations to make
Feet and ankles:
Look for inversion, eversion, toeing out, low or high
arches. The feet are often associated with knee, hip and
back problems. Look for calluses on the feet, this is a
good indicator that there could be a biomechanical
failure.

Knees:
Creases behind the knees - are they equal in height? Is
the patellae at the same height and central or pushed to
one side?
• Buttock:
Observe the height of creases – are they equal?
Pelvic Brim:
Is the height equal or rotated

• Back:
Are there an equal number of skin folds? Look for
differences in muscle size and shadows/contours of
the skin.
• Spine:
The spine has natural curvatures these can
become exaggerated in one direction or another
and the client can present with postural conditions
such as flat back, sway back, lordotic-kyphotic
and scoliosis.

Scapulae:
Are there any height differences in the inferior
angle? Do they rest flat against the upper back or
is there “winging”?

Shoulders:
Are they level or is one higher? Is the distance
from the acromion process to the cervical spine
the same?
• Arms:
How do they hang at the sides? Are they hanging close
to the sides or sitting away from the body? Are the
“windows” equal?

Head:
The head should not be tilted, retracted, rotated or
forward. The eyes should stay on a level plane, vertically
and horizontally, hence, a client can have an
exacerbated spinal curvature but the head will adjust
itself to compensate because of this tendency.
Evaluation
Lateral Evaluation
• Plumb Alignment: aligned anterior to lateral malleolus
Things to Examine
• Position of knees
– Check for hyperextension or flexion
• Pelvic position and spine curvature
• Head, chest and abdominal position
Lateral: Knee Position

Flexion of Knees Hyperextension of

Good Alignment
knees
Anterior Evaluation
• Position of feet
– Check for pronation or supination
– Check arch of the foot
• Position of legs
– Check for bowlegs
• Position of knees
– Check for knock-knees
• Appearance of ribs
• Position of head
Anterior: Good Alignment

Knee caps face

straight ahead

Legs are straight

up and down Arches have
normal half-dome
shape
Toes are straight
 Anterior: Foot Supination &
Pronation

Slight
knee
knocking

Contracted
anterior Feet are Weight is
tibalis Feet are pronated
supinated on outside
of feet
Evaluation
Posterior Evaluation
• Plumb Alignment- align midway between heels
Things to Examine
• Note alignment of Achilles Tendon
• Hip adduction/abduction
• Check for level posterior iliac spine
• Check for lateral pelvic tilt
• Check for spine and shoulder problems
 Tests for Postural Faults
The Mirror Test- (Anterior View)

Stand facing as full length mirror and check to see if:

• your shoulders are level

• your head is straight; no chin deviation; ears are level
• the spaces between your arms and sides are equally
spaced
• your iliac crests and hips are level
• kneecaps face straight ahead
• a 5° foot flare is shown
• arches are not flat
• no evidence of scrunching of the toes
TRADITIONAL METHOD
• Posture is measured by attempt to align significant bony
anatomical landmarks.
• Normal alignment usually is used following the
guidelines of Kendall & McCreary,1983.
• Lobe of the ear
• 7th cervical vertebra
• Acromial process
• Greater trochanter
• Anterior to the midline of the knee
• Anterior to the lateral malleolus
OTHER METHODS
• Researchers have used a range of tools to assess changes in
posture:

• RATING SCALE FOR SUBJECTIVE ASSESSMENT OF ANY

OBSERVED DEVIATIONS FROM NORMAL.

• FLEXIRULER (BURTON,1986)

• PHOTOGRAPHY (KEEGAN,1953)

• LORDISOMETRY/ SPONDYLOMETRY (TICHAVER ET AL,1973)

• INCLINOMETER (BULLOCK-SEXTON,1993)
POSTURE RATING SCALE
• Evaluating Posture
• PURPOSE
• The purposes of this laboratory session are as follows:
• To learn to recognize postural deviations and thus
become more posture conscious.
• To determine your posture limitations in order to institute
a preventive and corrective program
PROCEDURE
• Wear as little clothing as possible (bathing suits are
recommended) and remove shoes and socks.
• Work in groups of two or three, with one person acting
as the "subject" while partners serve as "examiners,"
then alternate roles. Note: The instructor may prefer to
conduct all examinations by individual screening exams
or posture photographs.
– Stand by a vertical plumb line.
– Use chart 16.3 below. Check any deviations and indicate their
severity as follows: 0 - none; 1 - slight; 2 - moderate; 3 - severe
• 1 - slight; 2 - moderate; 3 - severe
• · If time permits, perform back and posture exercises
assigned by your instructor.
RESULTS

Record your posture score _______________

Record your posture rating from the _______________

Posture Rating Scale

Posture Evaluation
Side View Points Back View Points
Head forward _____ Tilted head _____

Sunken chest _____ Protruding scapulae _____

Round shoulders _____ Symptoms of scoliosis _____

Shoulders uneven _____

Kyphosis _____ Hips uneven _____
Lordosis _____ Lateral curvature of _____
spine
(Adam's position)

Abdominal ptosis _____ One side of back high _____

(Adam's position)
Hyperextended knees

Body lean _____

Total Score _____
Posture Rating Scale
Classification Total Score

Excellent 0-2

Very Good 3-4

Good 5-7

Fair 8-11

Poor 12 or More
Postural Analysis & Assessment
includes…
1. Static Postural Assessment
2. Dynamic Postural Assessment
3. Gait analysis
4. Flexibility assessment
5. Muscle testing
Static Postural Assessment…
• Standing on both feet: front, side and rear
• views
• Standing on one leg
• Sitting supported and unsupported
• Kneeling
• Supine
• Sleeping
Dynamic Postural Assessment…
• Performing:
• A push- up
• A squat- with arms in front, lifting overhead
• A lunge
• Walking
• Lifting
Upper Cross Syndrome
Upper Body Overview:
WEAK TIGHT RESULTING IN COMMON
INJURIES
Longus Capitis Pectorals Forward head Headaches
& Coli Internal Rotators posture Rotator cuff
Hyoid muscle Upper Trapezius Depressed sternum impingement
Serratus Anterior Levator Scapulae Anterior migration of
Rhomboids Sternocleidomastoid shoulder girdle Thoracic outlet
Middle & Lower Anterior Scalenes Increased thoracic syndrome
Trapezius Suboccipitals kyphosis
Posterior Rotator Teres Major Internal rotation of
Cuff Anterior Deltoid humerous
Latissimus Dorsi
Lower Cross Syndrome

Lower Body Overview

WEAK TIGHT RESULTING IN COMMON
INJURIES
Rectus Rectus Femoris Anterior tilt/ Low back pain
Abdominus Iliopsoas rotation of pelvis Knee pain
Transverse & Erector Spinae Increased lumbar Hamstring strains
Obliques Quadratus lordosis
Gluteus maximus Lumborum Hips in flexion
Guteus Medius Tensor Fascia Latae
Hamstrings Adductors Knees hyper-extended
 Correction Poor Posture
• There are many therapies or treatments on
how to treat posture and the alignment of the
body parts, some of them are:
• Alexander Technique
• CranioSacral Therapy
• Physical Therapy
• Tai Chi
• Yoga
• Osteopathy
• Feldenkrais Method
• Chiropractic
• Rolfing
• All of them try to find the way in which good
posture is achieved with the less effort applied.
Figure 5. Landmarks for assessing pelvic tilt are shown above.
FUNCTIONAL CLASSIFICATION OF
MUSCLE
Vladamir Janda discovered that muscles can be
categorized as either postural, phasic, or a mixture of the
two.
• Postural muscles
• Phasic muscles
POSTURAL MUSCLES

• Act predominantly to sustain your posture in the gravity

field. These muscles contain mostly slow-twitch muscle
fibers and have a greater capacity for sustained work.
They are prone to hyperactivity.
• Postural muscles tend to shorten in response to over-
use, under-use or trauma.
PHASIC MUSCLES

• Contain mostly fast-twitch muscle fibers, and are

therefore more suited to movement. They are prone to
inhibition. They are also more easily fatigable.
• Phasic muscles tend to lengthen and weaken in
response to these types of stimuli.
• Postural muscles tend to shorten in response to over-
use, under-use or trauma, whereas phasic muscles tend
to lengthen and weaken in response to these types of
stimuli. These effects can lead to musculo-skeletal
imbalance and joint instability when postural and phasic
muscles are located on opposing sides of the agonist-
antagonist relationship.
• These relationships are the key to understanding
common patterns of postural imbalance such as the
upper-crossed and lower-crossed syndromes.
 Trunk
Lumbar Erector Spinae Thoracic Erector Spinae
Cervical Erector Spinae Rectus Abdominis
Quadratus Lumborum Transversus Abdominus

Pelvis - Thigh
Hamstrings
Iliopsoas
Vastus Lateralis
Rectus Femoris
Vastus Medialis
Adductors
Gluteal Muscles
Piriformis
Tensor Fasciae Latae

Lower Leg - Foot

Tibialis Anterior
Gastrocnemius
Peroneals
Soleus
Toe Extensors
Postural Muscles Phasic Muscles
Shoulder Girdle - Arm

Pectoral Muscles
Levator Scapulae Trapezius (middle)
Trapezius (upper) Trapezius (lower)
Biceps Brachii Serratus Anterior
Scalenes Triceps Brachii
Subscapularis Deep Cervical Flexors
Sternocleidomastoid Supraspinatus
Suboccipitals Infraspinatus
Masseter Deltoid
Temporalis Wrist & Finger Extensors
Wrist & Finger Flexors
What is the correct way to stand?

• 1. Hold your head up straight with your chin in. Do not tilt
your head forward, backward or sideways.
• 2. Make sure your earlobes are in line with the middle of
your shoulders.
• 3. Stretch the top of your head toward the ceiling.
• 4. Keep your shoulders back, your knees straight and
your back straight.
• 5. Tuck your stomach in. Do not tilt your pelvis forward.
• 6. The arches in your feet should be supported.
What is the correct way to sit?
1. Sit up with your back straight and your shoulders back.
Your buttocks should touch the back of your chair.
2. All three normal back curves should be present while
sitting. A small, rolled-up towel or a lumbar roll can be
used to help you maintain the normal curves in your
back.
3. Here's how to find a good sitting position when you're not
using a back support or lumbar roll:
a. Sit at the end of your chair and slouch completely
b. Draw yourself up and accentuate the curve of your
back as far as possible.
c. Hold for a few seconds
d. Release the position slightly (about 10 degrees). This
is a good sitting posture.
4. Distribute your body weight evenly on both hips.
• 5. Bend your knees at a right angle. Do not sit with your
knees crossed. Keep your knees even with or slightly
higher than your hips.
• 6. Keep your feet flat on the floor.
• 7. Try to avoid sitting in the same position for more than 30
minutes.
• 8. At work, adjust your chair height and work station so
you can sit up close to your work and tilt it up at you. Rest
your elbows and arms on your chair or desk, keeping your
shoulders relaxed.
• 9. When sitting in a chair that rolls and pivots, don't twist at
the waist while sitting. Instead, turn your whole body.
• 10. When standing up from the sitting position, move to
the front of the seat of your chair. Stand up by
straightening your legs. Avoid bending forward at your
waist. Immediately stretch your back by doing 10 standing
backbends.
• It is ok to assume other sitting positions for short periods of time,
but most of your sitting time should be spent as described above
so there is minimal stress on your spine.
What is the correct way to sit while
driving?
1. Use a back support (lumbar roll) at the curve of your
back. Your knees should be at the same level or higher
than your hips. "

2. Move the seat close to the steering wheel to support the

curve of your back. The seat should be close enough to
allow your knees to bend and your feet to reach the
pedals.
What is the best position for sleeping and
lying down?
• The best lying or sleeping position may vary, depending
on your symptoms. No matter what position you lie in,
the pillow should be under your head, but not your
shoulders, and should be a thickness that allows your
head to be in a normal position. "

• 1. Try to sleep in a position which helps you maintain the

curve in your back (such as on your back with a pillow
under your knees or a lumbar roll under your lower back;
or on your side with your knees slightly bent). Do not
sleep on your side with your knees drawn up to your
chest. You may want to avoid sleeping on your stomach,
especially on a saggy mattress, since this can cause
back strain and can be uncomfortable for your neck.
• 2. Select a firm mattress and box spring set that does
not sag. If necessary, place a board under your
mattress. You can also place the mattress on the floor
temporarily if necessary. If you've always slept on a soft
surface, it may be more painful to change to a hard
surface. Try to do what's most comfortable for you.

• 3. Try using a back support (lumbar support) at night to

make you more comfortable. A rolled sheet or towel tied
around your waist may be helpful.

• 4. When standing up from the lying position, turn on your

side draws up both knees and swings your legs on the
side of the bed. Sit up by pushing yourself up with your
hands. Avoid bending forward at your waist.