Posture of The Head, Shoulders & Thoracic Spine In Comfortable Erect Standing; Summary and Short Critical Review. 

  • by 0016802157
  • 16 Aug, 2017
Article written by Sally Raine and Lance Twomey (1994).
Sports massage, Osteopathy, Leagrave, Luton
Are you holding your posture correctly?
Figure 1
Short Study Summary:
  • The following study explored the importance of posture in relation to dysfunction and pain in the cervical and thoracic spine. 
  • The reliability of postural measurements of the head, shoulders and thoracic spine were studied in 39 young healthy adults.
  • Results overall showed that forward head posture and upper cervical spine extension tended to increase the kyphosis of the  upper thoracic spine. Forward head position was  not necessarily found to be related to a  forward shoulder position nor  upper cervical spine extension.                    
Method:
  • 39 volunteers (31 female and 8 male) ranging in age from 17-48 years with an average of 22 years old participated in this study.
  • 6 measurements of posture were obtained.
  • Measurements of the subjects’ weight and sitting height (mm) were obtained.
Measurements:
1.) Anterior head alignment;
Points Measured:
  • Inferior margins of the left and right ears. 
  • 180 degree angle meant a horizontal and aligned head. 
2.)  Anterior Shoulder Alignment
Points Measured: 
  • Left and right coracoid process.
  • A 180 degrees angle meant that the shoulders are held at the same level.
3.) Sagittal (lateral) Plane Head Alignment
Points measured:
  • Between vertebra C7 to the tragus of the ear. 
  • When the angle of degrees value reduced, a more forward head position was described.
4.) Head Alignment from the Frankfurt Plane (Figure 1) 
Points Measured:
  • Between posterior margin of the tragus of the ear to the orbitale.
  • An angle of 180 degrees represented the Frankfurt horizontal plane and described the head position to be horizontal. 
  • An angle less than 180 degrees meant that the orbitale was superior to thetragus and the upper cervicalspine was relatively extended. 
  • An angle greater than 180 degrees meant that the orbitale was inferior to thetragus of the ear and the upper cervical spine was relatively flexed.
5.) Sagittal Plane Shoulder Alignment
Points Measured:
  • C7 vertebra and the humeral head of the left shoulder.
  • The lesser the angle between two points meant the more rounded position of the shoulder.
6.) Upper and Lower Thoracic Curvature:

  • Regions C7-T6 and T6-T12 (upper and lower regions of the thoracic spine)
  • Heights if curves were measured during a sitting position. 
7.) Weight and Sitting Height
Results;  
  • Each subject was measured in kgs.
  • Two photographs were taken of each subject whilst standing and taken from the person's side on and frontal view (Figure 3 and Figure 4 in the study article).
  • When the orbitale (eye socket) was held more superiorly with respect to the tragus of the ear, the shoulders were positioned more forward (held in protraction).
  • A correlation was found between increased extended upper cervical spine and protractedly held shoulders.
  • When the resting head position is anterior (forward head lag) with respect to C7, an increased curvature of the upper thoracic spine results.
  • Supported the observation that people, overall tend to demonstrate asymmetrical shoulder height in the coronal (vertical) plane.
  • Increased extension of the upper cervical spine meant a slight upward tilt of the orbitale from the Frankfurt horizontal plane (Figure 1).
  • No significant difference was found between men and women for head and shoulder posture.
  • No significant difference was found between men and women for the measurement of upper thoracic curvature.
  • A difference was found between men and women for lower thoracic curvature.
  • The average resting shoulder posture of subjects in the study was 47.6 degrees which represented a protracted resting position of sagittal (lateral) plane shoulder alignment.
  • The position of the head in the sagittal plane was found to be related to the curvature of the upper thoracic spine. If the head was positioned more anteriorly with respect to the trunk, an increased flexed curvature between C7-T6 was found (increased thoracic spine kyphosis).
  • A forward head posture did not indicate forward or protracted shoulders as may have been expected when measured with respect to the trunk. The results did not support the observation that a forward head is always associated with rounded shoulders.

Short Table Summary of Study Findings;
Sports Massage, Osteopathy, Leagrave, Luton
Table summary of head and mid back posture
Conclusion:
  • Overall, a   forward head posture and upper cervical spine extension tended to increase the kyphosis of the   upper thoracic spine. However, the results for the correlative relationships was not found to be significant.
  • A   forward head position was  not necessarily found to be related to a   forward shoulder position nor   upper cervical spine extension when measured in the sagittal plane.
Short critical analysis;
  • This was a small scale study with 39 healthy, young volunteers involved.
  • The majority of individuals were female (31 female and 8 male) with an average of 22 years of age.
  • A larger study with a even number of males and females would have been required to possibly gain a more significant result.
  • This article was published in 1994 and it would be interesting to study the difference with regards to technological advances since then for measuring posture.
Journal Reference:
by 0016802157 13 Oct, 2017

ByunghHo J. K., JungHoon, A., HeeCheol, C., DongYun, K., TaeYeong, Kim., BumChul, Y. (2015) Rehabilitation with Osteopathic Manipulative Treatment (OMT) After Lumbar Disc Surgery: A Randomised, Controlled Pilot Study , IJOM: 18; 181-188.

 Study Summary:

  • 33 patients who had underwent lumbar microdiscectomy were randomly assigned to one of two intervention groups; either exercise programme or an OMT group post surgery.
  • Both intervention programmes (Exercise and OMT) consisted of 8 individual sessions which were performed twice a week for 4 weeks.
  • Each session was 30 minutes and all patients in both groups were prescribed supplementary anti inflammatory medication, analgesics and a muscle relaxant by surgeon.
  • Results showed reduced residual leg pain after the lumbar discectomy in the OMT group with a 53% reduction compared to the exercise group which had a 17% reduction.
  • Residual lower back pain also decreased in both interventions with a 37% reduction in the OMT group and a 10% reduction in the exercise group.
  • No side effects or complications from any intervention were reported.
  • Patients in the groups required less frequent use of medication with an 87% reduction in the OMT and 73% in the exercise.
  • An overall improvement was found in the lumbar spine active ROM with patients being able to move without pain in both the OMT group and exercise groups.

Introduction

  • Low back pain is a worldwide health problem with a lifetime prevalence rate of 80% and can affect daily physical activity (1.).
  • Lumbar disc pain accounts for less than 5-10% of lower back pain (LBP) and is one of the most common reasons for lumbar spine surgery (2).
  •   Lumbar discectomy is one of the most commonly performed operations for lower back pain to relieve nerve root pain and reduce physical disability.
  • The most common unsatisfactory complaints complications observed in patients following lumbar discectomy are;

  1. Continued post operative physical disability affecting daily activities.
  2. Residual lower back pain and leg pain (3.).

Post surgical intervention has been considered important to reduce post surgical physical complications and increase the success rate for patients post surgery.

This study performed a pilot study comparing Osteopathic Manipulative Treatment (OMT)  with exercise following lumbar disc surgery to assess the feasibility for a future randomised control trial.

Study Method

  • 48 patients who met the eligibility criteria and wanted to participate in the study were interviewed and screened by two research surgeons.
  • The study was a randomised controlled pilot study and conducted at a major metropolitan spine surgery hospital where all participants underwent lumbar microdiscectomy.
  • Two research spinal surgeons registered in Korea and a research osteopath registered in the UK conducted patient recruitment and screening.
  • The study protocol was approved by the institutional review board of the University of Korea, and all participants provided written informed consent.
  • Patients between 20 and 65 years of age who had lower back pain and referred leg pain resulting from a herniated lumbar disc and underwent lumbar microdiscectomy were identified by hospital nurses.

Patient Exclusion Criteria:

  • A requirement of revision surgery or other forms of combined surgery.
  • A refusal to participate
  • Contraindication for participation including pregnancy, metastatic disease, or a mental disorder.
  • Of the 48 patients, 15 were excluded and the remaining 33 were randomly allocated to either the OMT group or the exercise programme group.

Study Procedure

  • 33 patients who had underwent lumbar microdiscectomy by 2 neurosurgeons at the spine surgery hospital returned to the hospital 2 to 3 weeks after surgery for baseline measurements and the first rehabilitation intervention.
  • Each participant was randomly assigned to one of two intervention groups; either exercise programme or an OMT group.
  • The allocations were conducted using simple randomisation.
  • Both intervention programmes (Exercise and OMT) consisted of eight individual sessions which were performed twice a week for 4 weeks. Each session was 30 minutes and all patients in both groups were prescribed supplementary anti inflammatory medication, analgesics and a muscle relaxant by surgeons.

Intervention OMT Rehabilitation & Techniques Used:

  • All patients underwent physical assessment before each intervention.
  • The same practitioner applied a combination of techniques in the standardised protocol for the OMT but the intensity and sequence of the techniques were modified for each patient depending on their tolerance to treatment and other post-operative physical conditions.
  • The protocol did not include spinal high-velocity, low-amplitude thrust (HVLAT) manipulation of the lumbar segments where the surgery was performed.
  • The focus of the OMT protocol was to reduce biomechanical overload on the lumbar spine by functionally improving the motion of adjacent spinal segments or joints including the thoracic and cervical segments and the sacroiliac joint.
  • The protocol included techniques applied to myofascial structures to reduce post-operative physical tension and stiffness generated in the body.
  • Each OMT intervention was performed by two osteopathic students under the supervision of a qualified osteopath.
  • Each treatment process was documented and reviewed by a research osteopath and surgeon.

Exercise Programme

  • Overall, 8 exercise sessions were conducted over a course of 4 weeks.
  • The aim of the exercise programme was to improve spinal mobility and stabilise the lumbar segments.
  • For the first week, practitioners focused on stretching exercises for the back and abdominal muscles with the patient in the supine position.
  • For the 2nd and 3rd week, practitioners focused on isometric strengthening exercises for the back and hip extensors with the patient in the prone position or sitting on a gym ball.
  • In the final 4th week, the intensity of the previous exercises was increased and back stability exercises were performed using a pilates exercise apparatus.

Outcome measures

  • Outcome measures were assessed after 2 and 3 weeks post surgery and post-intervention.
  • A post-intervention evaluation was conducted 7 to 8 weeks post surgery which was otherwise a week after the final rehabilitation session.
  • Primary outcome measures were evaluated for post-operative disability and residual pain in the legs and lower back.
  • Outcome measure questionnaires used were the Rolande Morris Disability Questionnaire (RMQ) with a 24-point scale and the Visual Analogue Scale (VAS) with 0 indicating ‘no pain’ and 100 indicating ‘the worst pain’.
  • Secondary outcomes included lumbar range of motion (ROM), use of medication, and patient satisfaction.
  • The lumbar spine ROM at which the patients could move without pain was measured with a double inclinometer by a physiotherapist who was not involved in any intervention.
  • The number of supplemental medications taken per week was used to assess medication consumption.
  • Patients were also asked to fill in a self-grading questionnaire to evaluate their satisfaction for their rehabilitation intervention which indicated ‘dissatisfaction’, ‘moderate satisfaction’ and ‘total satisfaction’.
  • Patients were asked whether they would recommend the rehabilitation intervention they received to a family member or friend with a similar condition.

Statistical Analysis

  • The Shapiroe Wilk test was used to assess normality of distribution of the data. Medians are shown for the range of movement found in lumbar spine extension and left side-bending, and for the number of times medication was used.
  • The categorical data was analysed using the chi-square test or Fisher’s exact test to account for baseline variations.
  • The Student‘s t-test or the Manne Whitney U test was applied to compare the differences between the groups. SPSS statistical software (Version 12.0, SPSS Inc., Chicago, IL) was used for the analyses. Two-sided tests and a significance level of 0.05 were used for all statistical analyses.
  • Subjects Of the 48 patients deemed eligible for inclusion, 33 (69%) were enrolled and randomly allocated to either the OMT or exercise group.
  • There were no significant differences in baseline characteristics and baseline measures between the two groups.
  • The primary reason for non-enrolment was lack of interest in participation. Of the enrolled patients, 6% were lost to follow-up at the primary study endpoint (2 of 33, 1 in each group). All 33 patients who were randomly assigned to a group were analysed on an intention-to-treat basis.

Primary Outcome Results

  • Primary outcomes OMT and the exercise programme improved all primary outcomes.
  • Post-surgical physical disability questionnaire results showed that patients improved more after OMT rehabilitation than the exercise group.
  • Residual leg pain after the lumbar discectomy decreased in the OMT group with a 53% reduction compared to the exercise group which had a 17% reduction.
  • Residual lower back pain also decreased in both interventions with a 37% reduction in the OMT group and a 10% reduction in the exercise group.

Secondary Outcome Results

  • An overall improvement was found in the lumbar spine active ROM with patients being able to move without pain in both the OMT group and exercise groups.
  • Patients in the groups required less frequent use of medication with an 87% reduction in the OMT and 73% in the exercise.
  • Patients in both groups responded that they were highly satisfied with the post-operative rehabilitation and answered that they would recommend the post-operative rehabilitation to a family member or a friend undergoing spinal surgery.
  • No side effects or complications from any intervention were reported.

Table Of Results
by 0016802157 16 Aug, 2017
Article written by Sally Raine and Lance Twomey (1994).
by 0016802157 27 Jul, 2017
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