Examples of how structural and functional features strongly influence each other.
We all know that poor posture is damaging to our physical structures, but are we as aware of the wider implications of postural distress on the total economy of the body, and even on organ function? To explore that topic deeply would take a book − or two − so the best I can offer in this brief review are some hopefully thought-provoking snippets of information.
One of the best discussions of the influences of postural/biomechanical misalignment on the economy of the body and on organ function was provided by the orthopaedic surgeon Joel E.
Goldthwaite in the 1930s, in his classic book Essentials of Body Mechanics. (Search for this via Web sites that specialize in secondhand books. It’s a marvellous text.)1 The concepts described by Goldthwaite, and subsequently developed by others (see below), are extremely relevant to all health care professionals. They demonstrate the inevitable progression to which poor posture leads as tissues adapt to postural imbalance, with the influences of aging and gravity adding to the picture. For a dramatic and graphic account of the process of decompensation, I am quoting directly from Goldthwaite, who observed:
“The main factors which determine the maintenance of the abdominal viscera in position are the diaphragm and the abdominal muscles, both of which are relaxed and cease to support in faulty posture. The disturbances of circulation resulting from a low diaphragm and ptosis [‘sagging’], may give rise to chronic passive congestion in one or all of the organs of the abdomen and pelvis, since the local, as well as general venous drainage, may be impeded by the failure of the diaphragmatic pump to do its full work in the drooped body. Furthermore, the drag of these congested organs on their nerve supply, as well as the pressure on the sympathetic ganglia and plexuses, probably causes many irregularities in their function, varying from partial paralysis to overstimulation. All these organs receive fibers from both the vagus and sympathetic systems, either one of which may be disturbed. It is probable that one or all of these factors are active at various times in both the stocky and the slender anatomic types, and are responsible for many functional digestive disturbances. These disturbances, if continued long enough, may lead to diseases later in life. Faulty body mechanics in early life, then, becomes a vital factor in the production of the vicious cycle of chronic diseases and presents a chief point of attack in its prevention … In this upright position, as one becomes older, the tendency is for the abdomen to relax and sag more and more, allowing a ptosic condition of the abdominal and pelvic organs unless the supporting lower abdominal muscles are taught to contract properly. As the abdomen relaxes, there is a great tendency towards a drooped chest, with narrow rib angle, forward shoulders, prominent shoulder blades, a forward position of the head, and probably pronated feet. When the human machine is out of balance, physiological function cannot be perfect; muscles and ligaments are in an abnormal state of tension and strain. A well-poised body means a machine working perfectly, with the least amount of muscular effort, and therefore better health and strength for daily life.”
Because it is so graphic, I have added italics to the description Goldthwaite offers of the slumped posture that is so apparent in many of our patients − you could draw the picture of this person, I am sure! Obviously, a huge amount of study and research has continued into the widespread influences of poor posture on health in the 70 years since Goldthwaite published these words. One of the most interesting perspectives comes from Professor Wolf Schamberger, who sets out in his book The Malalignment Syndrome2 a current, clinical and research-based view that totally supports the earlier Goldthwaite observations. Schamberger describes some of the inevitable changes that are associated with common asymmetries, as follows:
“Malalignment of the pelvis, spine and extremities remains one of the frontiers of medicine … the associated biomechanical changes – especially the shift in weight-bearing and asymmetries of muscle tension, strength, joint ranges of motion − affect soft tissues, joints and organ systems throughout the body and therefore, have implications for general practice and most medical sub-speciality areas.”(Italics added)
Schamberger offers examples of visceral problems emerging from malalignment of the pelvis, resulting, for example, in pelvic floor dysfunction:
“Typical visceral problems that have been attributed to pelvic floor dysfunction include:
- Incontinence of bowel and bladder attributed to a lax floor.
- Constipation and incomplete voiding when there is excessive tension.
- Dysmenorrhoea, dyspareunia, impotence and sexual dysfunction.
- Recurrent cystitis and urinary tract infection.”3,4,5
Osteopathic clinical researcher Kuchera6 has looked at the effects of gravity on posture: “Gravitational force is constant and a greatly underestimated systemic stressor. Of the many signature manifestations of gravitational strain pathophysiology (GSP), the most prominent are altered postural alignment and recurrent somatic dysfunction. … Recognizing GSP facilitates the selection of new and different therapeutic approaches for familiar problems. The precise approach selected for each patient, and its predicted outcome, are strongly influenced by the ratio of functional disturbance to structural change.”
Kuchera adds a perspective that highlights some of the other key influences on what they termpostural decay:
“Posture is distribution of body mass in relation to gravity over a base of support. The efficiency with which weight is distributed over the base of support depends on the levels of energy needed to maintain equilibrium (homeostasis), as well as on the status of the musculo-ligamentous structures of the body. These factors − weight distribution, energy availability and musculo-ligamentous condition − interact with the (usually) multiple adaptations and compensations which take place below the base of the skull, all of which can influence the visual and balance functions of the body.”
Over time, adaptational changes, as listed by Goldthwaite, Kuchera and Schamberger, are likely to progress from the production of dysfunction (such as low back pain) to the evolution of actual pathological changes. These examples show how structural and functional features strongly influence each other, and how other factors, ranging from age to available energy, musculo-ligamentous status and gravity, all help determine the changes that evolve.
One more example highlights how patterns of use − in this example, changes created by poor breathing function − can have marked influences on structures and organ function, on top of those imposed by the influences of poor posture. Garland7 has summarised a series of changes that follow from unbalanced breathing habits, including: “visceral stasis/pelvic floor weakness, abdominal and erector spinae muscle imbalance, fascial restrictions from the central tendon via the pericardial fascia to the basi-occiput, upper rib elevation with increased costal cartilage tension, thoracic spine dysfunction and possible sympathetic disturbance, accessory breathing muscle hypertonia and fibrosis, promotion of rigidity in the cervical spine with promotion of fixed lordosis, reduction in mobility of the 2nd cervical segment and disturbance of vagal outflow … and more.”
In order to evaluate posture, observation and palpation, specific assessments are needed. The basic requirements include:
- Observation: checking key anatomical landmarks and aspects of alignment and balance, with the patient both static and active: standing, walking, sitting, and reclining.10
- Postural evaluation: observation of patterns, including functional tests such as the scapulo-humeral rhythm test and core stability.8
- Gait analysis.
In a future issue of Massage Today, I will present some of the most effective palpation/assessment methods that can help us make sense of these changes, allowing effective treatment protocols to be developed.
- Goldthwaite J, Brown LT, Swaim LT, Kuhns, JG. Essentials of Body Mechanics in Health and Disease. Philadelphia: Lippincott, 1945.
- Schamberger W. The Malalignment Syndrome. Edinburgh: Churchill Livingstone, 2002, pp238-39.
- Costello K. Myofascial Syndromes. In: Chronic Pelvic Pain: An Integrated Approach, Steege J, Metzger D, Levy B, Eds. Philadelphia: WB Saunders, 1998, pp251-66.
- Barral J-P, Mercier P. Visceral Manipulation II. Seattle: Eastland Press, 1989.
- Herman H. Urogenital Dysfunction. In: Obstetric and Gynecologic Physical Therapy, Wilder E, Ed. New York: Churchill Livingstone: New York, 1988, pp83-111.
- Kuchera M. Treatment of Gravitational Strain. In: Movement, Stability, and Low Back Pain,Vleeming A, Ed. New York: Churchill Livingstone, 1997
- Garland W. “Somatic Changes in Hyperventilating Subject.” Presentation at Respiratory Function Congress, Paris, 1994.
- Lewit K. Manipulative Therapy in Rehabilitation of the Motor System, 3rd ed. London: Butterworth-Heinemann, 1999.
- Liebenson C. Rehabilitation of the Spine 2nd ed. Baltimore: Williams and Wilkins, 2005.