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Is a patient’s posture relevant to their symptoms ….or is that concept out of date?

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In a recent facebook discussion/thread, in response to a question,  I described a potential sequence that might predispose an individual to shoulder pain/dysfunction.

My words in that post were:

“An individual whose posture could be summarised as ‘slumped, would carry the head forward of its centre of gravity, with protracted shoulders, probable thoracic kyphosis etc. This would carry the glenoid fossa into an anatomical position which would place stresses on (for example) the rotator cuff muscles. A simple scapulo-humeral rhythm test would probably demonstrate relatively high tone in these rotator cuff muscles, upper trapezius, cervical extensors etc – with predictable hypotonicity (‘weakness’) in their antagonists and – for example – poor scapular stabilisation.
Clinically this individual is likely to experience shoulder and or neck discomfort at times, and possibly pain.
I would expect on palpation to find a degree of increased ‘density’/ induration in the hypertonic muscles, and sensitivity/pain on moderate pressure/stretching.
Now I see this as a common pattern (poor posture, Janda’s ‘upper crossed syndrome’) which could be relieved, improved, corrected (depending on age and other variables) via postural reeducation and functional exercise…. and I would suggest, by local interventions that attempt to improve the local soft-tissue and joint environment, using methods such as those described in my previous post on this page “Muscle energy techniques for joints – shoulder as an example”
I would anticipate that circulatory efficiency would improve as hypertonicity reduced due to postural reeducation, functional exercises and local treatment – especially the ‘pulsed muscle energy approach described in the ‘shoulder’ post since it involves repetitive rhythmic isometric contractions.”

To summarise – my suggestions were:

a/ A slumped posture, with protracted shoulder, would position the glenoid fossa anteriorly and that this would result in the major muscles responsible for shoulder movement being at a mechanical disadvantage, potentially resulting in neck and/or shoulder discomfort (and possibly pain)

b/ That a part of this imbalance would likely involve a degree of unstable scapular function

b/ That this could be partially evaluated by use of the scapulo-humeral rhythm test

c/ That functional exercises, postural reeducation and local treatment, could probably relieve, improve or correct the situation, depending on age and other variables.

One negative response to that description was:

“You state you use observing scapula, shoulder girdle positions and Janda’s models as justification for poor or ‘dysfunctional’ postures.  These models are woefully archaic, out dated, poorly evidenced biomedical paradigms. Trying to blame a ‘poor posture’ onto patients who see us when in pain is simply flawed. This method of thinking and assessment holds no place in any modern therapists biopsychosocial approach to MSK assessment and management.” (My emphasis added)

A different response to my post was:

“Questions should be asked and answered regarding what manual therapy does and [we should] not provide our patients with narratives that may, in the long run, be unhelpful. Janda’s crossed syndrome above may be such an example.”

I therefore feel obliged to re-examine my rationale and my  clinical approach.

  • Is the Janda model ‘archaic and out-dated”?
  • Is this a “poorly evidenced biomedical paradigm”?
  • Does  discussion of posture with a patient “blame’ them, and is it unhelpful?

 A rapid ‘google scholar’ search (using ‘crossed syndrome’ and ‘shoulder’ as key words – brought up these papers – there are many others :

Stanos et al note the following in their 2007 paper Physical Medicine Rehabilitation Approach to Pain :

“ROM, muscle strength, and balance should be assessed because deficits in this area can affect a patient’s ability to perform the activities of daily living and achieve efficient functional mobility. Active ROM, active assistive ROM, and passive ROM can be assessed for each joint. The examiner should note general hypermobility or hypomobility, side-to-side differences in ROM, and which of the movements result in pain. The findings on ROM testing combined with the results of manual muscle testing may lead to objective findings of muscle imbalances about a joint. This concept has been well described by Janda and colleagues  as the upper-crossed and pelvic-crossed syndromes. An upper-crossed syndrome is characterized by contracted and hypertonic postural muscles (pectoralis major and upper trapezius) and lengthened phasic muscles (rhomboids, serratus anterior, middle and lower trapezius), which may present with related neck and shoulder pain and headaches.” (my emphasis added)

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IMAGE FROM Stanos et al paper

CAPTION : Posture. (A) Good standing posture. Note the normal cervical and lumbar lordosis and thoracic kyphosis. (B) Poor standing posture. The shoulders are rounded forward. There is a loss of lumbar lordosis and an exaggeration of the thoracic kyphosis. (C) Good sitting posture. The normal cervical, thoracic, and lumbar curvatures are maintained. (D) Poor sitting posture. The shoulders are rounded forward. The there is a loss of the normal lumbar and thoracic curvatures. The neck is in compensatory hyperextension.

My reading of this suggests that postural influences and muscular imbalances – as described-  may be associated with neck and shoulder pain.

Page (2011) notes in his paper: Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes Int J Sports Phys. Ther.  6(1): 51-58 :

“The shoulder complex relies on muscles to provide dynamic stability during its large range of mobility. Proper balance of the muscles surrounding the shoulder complex is also necessary for flexibility and strength; a deficit in flexibility or strength in an agonistic muscle must be compensated for by the antagonist muscle, leading to dysfunction. These muscular imbalances lead to changes in arthrokinematics and movement impairments, which may ultimately cause structural damage.” (my emphasis added)

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IMAGE FROM Page paper

Caption:  Janda’s Upper Crossed Syndrome.

My reading of this suggests that posturally related  muscular imbalances – as described-  may be associated with ‘structural damage’

 Barczyk-Pawelec et al 2012  in their paper: Anteroposterior Spinal Curvatures and Magnitude of Asymmetry in the Trunk in Musicians Playing the Violin Compared With Non-musicians. Journal of Manipulative and Physiological Therapeutics  35(4):319–326  note that:

Steinmetz et al conducted a study, which revealed that, “in a group of instrument players, pain was usually localized in the area of shoulders (26%), hands (17%), lumbar spine (13%), and wrists (12%). A study carried out by van Eijsden-Besseling et al (1993),which focused on clinically assessed postural parameters, revealed antero-position of the head, shoulder and pelvic asymmetry, thoraco-kyphosis, swayback, scoliosis, and lumbar lordosis. Fifty-four percent of the music students showed postural disorders. Many researchers confirm that prolonged assuming forced body positions necessary for playing a given instrument increased the probability of motor system overloading“. (my emphasis added)

AND

This study showed that musicians (violinists), when compared with a control group of non-musicians, were characterized by higher body mass and deeper and longer thoracic kyphosis, which in turn showed decreased angle of lumbar lordosis. The analysis of body posture in the frontal plane revealed that, in the group of musicians, the long-lasting, asymmetric position assumed while playing the violin caused significant asymmetries occurring mainly in the shoulder girdle, the width of the trunk-arm triangles, and deviation of the spinous processes from the perpendicular.

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IMAGE FROM Steinmetz et al  paper

CAPTION:  Pain regions (with major complaints, in %).

My reading of this suggests that a combination of postural and overuse factors make these musicians more vulnerable to painful episodes.

Heinlein S Cosgarea A 2010 Biomechanical Considerations in the Competitive Swimmer’s Shoulder. Sports Health 2(6):519-525  noted that:

“The average competitive swimmer swims approximately 60 000 to 80 000 m per week. With a typical count of 8 to 10 strokes per 25-m lap, each shoulder performs 30 000 rotations each week. This places tremendous stress on the shoulder girdle musculature and glenohumeral joint, and it is why shoulder pain is the most frequent musculoskeletal complaint among competitive swimmers. Because of the great number of stroke repetitions and force generated through the upper extremity, the shoulder is uniquely vulnerable to injury in the competitive swimmer.The relationship between the function of the shoulder girdle and the rest of the body is well recognized in throwing athletes (Burkhart et al 2003), and is relevant to the successful treatment of shoulder pain in swimmers. Comprehensive evaluation should include the entire kinetic chain, including trunk strength and core stability.”

10.1177_1941738110377611-fig2

IMAGE FROM Heinlein & Cosgarea paper

CAPTION: Muscle activity of the freestyle stroke based on electromyographic and cinematographic analysis.

This paper emphasises to me that overuse may be a key feature in the evolution of shoulder girdle dysfunction and pain – whether swimmers, violinists – or people texting on mobile telephones (see below) – suggesting  that a combination of ‘patterns of use’, possibly accompanied by postural stresses, are key elements that require attention in such conditions. 

 

Texting as a postural and overuse stress:

Lin IM, Peper E 2009 in their paper:  Psychophysiological patterns during cell phone text messaging: a preliminary study. Appl Psychophysiol Biofeedback. ;34(1):53-57  .

..observed 12 students, all familiar with texting, who were monitored with surface electromyography (SEMG), skin conductance (SC) from the palm of the non-texting hand, as well as for their respiration patterns.  Results indicated that ALL subjects showed significant increases in respiration rate, heart rate, SC, and shoulder and thumb SEMG – compared to baseline measures. 83% reported hand and neck pain during texting, and held their breath and experienced sympathetic arousal when receiving text messages. Most were unaware of these physiological changes. The study suggests that frequent triggering of these responses (freezing posture for stability + shallow breathing) may be related to the reported musculoskeletal symptoms.

My overall conclusion viewing these various studies and reports is that posture and patterns of use are clinically relevant, and that it is not inappropriate to inform patients that improved use of their body may be useful (i.e. not ‘unhelpful’) as part of the rehabilitation process; and that the postural patterns identified by Janda are neither archaic nor out of date.

Note that I do not point to these postural issues as specific causes of symptoms, but as part of comprehensive interlocking sequence of factors, involving features that might include overuse, previous injury, age, and other variables.  

Appropriate attention should include biomechanical education, together with manual and movement (as in functional exercise)  therapy interventions, as indicated  – as well as assisting patients to understand pain mechanisms.

Note also that all the papers referenced have shortcomings – however, that is also true of almost every research paper and review paper. It is the overall weight of evidence and clinical experience that provides me with my conclusions.

To return to the questions I asked myself at the start of this blog:

  • Is the Janda model ‘archaic and out-dated”?  No
  • Is this a “poorly evidenced biomedical paradigm”? I do not think so
  • Does  discussion of posture with a patient “blame’ them, and is it unhelpful? No

Clearly their are other ways of seeing the body, and different emphasis on different aspects – such as the biopsychosocial – but that need not detract from a postural, biomechanical degree of focus as well.

 POST SCRIPT ADDED 2 DAYS AFTER THIS BLOG WAS COMPLETED:

JANDA WAS CORRECT !!!!!

A comment on this  post (see ‘Comments” below) – from Dr Dale Thompson – confirms the link between shoulder dysfunction and posture. He has informed us of an article in the Journal of Shoulder & Elbow Surgery (2014) by Yamamoto et al –  entitled.

J Shoulder Elbow Surg. 2014 Oct 16. pii: S1058-2746(14)00423-6. doi: 10.1016/j.jse.2014.07.012. 

Abstract
HYPOTHESIS:
We hypothesized that the prevalence of rotator cuff tears would be higher among individuals with poor posture, regardless of the presence of symptoms.
METHODS:
The study initially comprised 525 residents of a mountain village who participated in an annual health check. Participants completed a background questionnaire, and physical examinations were performed to evaluate shoulder function. Ultrasonographic examinations were also performed to identify rotator cuff tears, and participants were grouped according to the presence or absence of tears. Posture was classified by 2 observers into 4 types according to the classification of Kendall, as follows: ideal alignment, kyphotic-lordotic posture, flat-back posture, and sway-back posture. Univariate analyses were performed to compare differences in background characteristics between groups, then multivariate analysis was performed to identify those factors associated with rotator cuff tears.
RESULTS:
Final analysis was performed for 379 participants (135 men, 244 women; mean age, 62.0 years; range, 31-94 years) showing the same posture classification from both observers. Of these, 93 (24.5%) showed rotator cuff tear in one shoulder and 45 (11.9%) showed tears in both. Prevalence of rotator cuff tears was 2.9% with ideal alignment, 65.8% with kyphotic-lordotic posture, 54.3% with flat-back posture, and 48.9% with sway-back posture. Logistic regression analysis identified increased age, abnormal posture, and past pain as factors associated with rotator cuff tears.
CONCLUSIONS:
Postural abnormality represented an independent predictor of both symptomatic and asymptomatic rotator cuff tears. These results may help define preventive measures for rotator cuff tears and in design ing rehabilitation therapies for shoulder disease.
Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
Rotator cuff tear; asymptomatic rotator cuff tear; epidemiology; etiology; faulty posture; population-based study

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Additional citations

  • Burkhart SS, Morgan CD, Kibler WB. 2003 The disabled throwing shoulder: spectrum of pathology. Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 19(6):641-661
  • M van Eijsden-Besseling et al 1993 Differences in posture and postural disorders between music and medical students Med Probl Perf Art, 8 (1993), pp. 110–114
  • Steinmetz A et al 2008 Shoulder Pain and Holding Position of the Violin –  Medical Problems of Performing Artists: 23(2)79

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