Postural Aberrations in Low Back Pain Heather J
Total Page:16
File Type:pdf, Size:1020Kb
218 Postural Aberrations in Low Back Pain Heather J. Christie, MSc(PT), Shrawan Kumar, PhD, Sharon A. Warren, PhD ABSTRACT. Christie H J, Kumar S, Warren S. Postural aberrations in low back pain. Arch Phys Med Rehabil 1995;76:218-24. • The purpose of this study was to measure and describe postural aberrations in chronic and acute low back pain in search of predictors of low back pain. The sample included 59 subjects recruited to the following three groups: chronic, acute, or no low back pain. Diagnoses included disc disease, mechanical back pain, and osteoarthritis. Lumbar lordosis, thoracic kyphosis, head position, shoulder position, shoulder height, pelvic flit, and leg length were measured using a photographic technique. In standing, chronic pain patients exhibited an increased lumbar lordosis compared with controls (p < .05). Acute patients had an increased thoracic kyphosis and a forward head position compared with controls (p < .05). In sitting, acute patients had an increased thoracic kyphosis compared with controls (p < .05). These postural parameters identified discrete postural profiles but had moderate value as predictors of low back pain. Therefore other unidentified factors are also important in the prediction of low back pain. © 1995 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation Low back pain is a significant problem in today's society, forces) on the joints that lead to excessive wear of the articu- with lifetime incidence rates reported between 50% and lar surfaces. 1°'16 With postural changes, a change in align- 90%. 1-3 Low back pain has recurrence rates of up to 90% 4,5 ment with respect to the line of gravity occurs that may lead even though many cases are self-limiting and require mini- to other adaptive postural changesJ 6'17 mal treatment. 5'6 Many factors associated with low back pain Posture is both static and dynamic and is assessed in a are reported including degenerative disc disease, sprains and variety of positions including sitting and standing, t8-2° strains, age, and occupation. 7'8 Low back pain may have Changes in alignment of body parts with respect to the center an insidious onset where the specific cause of the pain is of gravity may change between sitting and standing, 21 and unknown. 9 with the use of different chairs, t9'22 These changes can lead Clinical observations suggest that aberrations of posture to adaptive changes in other aspects of posture. 16'17 may play a role in the development of low back pain. t° Ideal posture has not been universally agreed to and sev- McKenzie 5 stated that low back pain (postural syndrome) eral different definitions have been advanced. 16.17.23 Even so, could result from prolonged overstretching of the innervated there is clinical consensus in the measurement of static stand- soft tissues when poor sitting or standing postures were ing and sitting postures. maintained. The ligaments of the spine (excluding ligamenta Some changes in posture are considered to be normal, fiava) are highly innervated and therefore may be of impor- whereas others have been associated with disease states such tance in the development of low back pain. ~-~3 Janda 14 as low back pain. When assessing static standing and sitting claimed that there was a unique, typical response of muscles posture, it is not uncommon to find the dominant shoulder to pain. The hamstrings and trunk extensors tended to re- to be lower 16 or to find leg-length discrepancies of up to spond by tightening, whereas the abdominals and glutei 1.0cm. 24 On the other hand, forward head posture is one tended to weaken and atrophy. Muscles that tended to tighten postural adaptation likely related to occupations and activi- usually had a postural function, whereas dynamic muscles ties requiring anterior head positions for prolonged periods. 25 tended to become weak. Alston and coworkers 15 found ham- Signs and symptoms such as pain in the lumbar spine and string tightness in individuals with low back pain and postu- pelvis are correlated with forward head posture) 6 There is lated that postural adjustments would be necessary to com- controversy in the literature regarding lumbosacral posture pensate for this tightness. Abnormal habitual postures can and low back pain. Thoracic kyphosis, lumbar lordosis, pel- cause abnormal stresses (increased shear or compressive vic tilt, and abdominal strength have all been investigated with respect to low back pain in various groups of sub- From the Department of Rehabilitation Services (Ms. Christie), St. Boniface Gen- jects.l°'27'28 eral Hospital, Winnipeg; Department of Physical Therapy (Dr. Kumar), University of Traditionally, postural evaluation and education have been Alberta; and the Faculty of Rehabilitation Medicine (Dr. Warren), University of Alberta, Canada. an important aspect of rehabilitation in individuals with low Submitted for publication July 5, 1994. Accepted in revised form October 4, 1994. back pain. 5'16'18'2° Much of the research previously cited in- Research completed in the Department of Physical Therapy, University of Alberta, vestigates only certain aspects of posture in any single study. to fulfill a requirement for the Master of Science Degree. No commercial party having a direct financial interest in the results of the research Health care professionals are concerned with the total indi- supporting this article has or will confer a benefit upon the authors or upon any vidual, not just single joints or limited body regions. There- organizations with which the authors are associated. Reprint requests to Heather Christie, MSc, PT, Department of Rehabilitation Ser- fore, it is important to have an understanding of a more vices, St. Boniface General Hospital, 409 Tacht, Winnipeg, MB, R2H 2A6 Canada. complete postural profile and any relationships between the © 1995 by the American Congress of Rehabilitation Medicine and the American individual parameters. Accordingly, the objectives of this Academy of Physical Medicine and Rehabilitation 0003-9993/95/7603-3141$3.00/0 study were to evaluate any static standing or sitting postural Arch Phys Med Rehabil Vol 76, March 1995 POSTURAL ABERRATIONS IN LOW BACK PAIN, Christie 219 aberrations in chronic and acute low back pain patients in calculated using the Quetelet index (weight/height 2 in comparison with healthy individuals, in search of potential kg/m2). 32 risk factors or associations for low back pain. Small balsa wood pointers, placed perpendicular to the surface of the curve, were used to mark the C7, T12 and L5 METHODS spinous processes. Dots were used to mark the tragus of the left ear, bilateral acromioclavicular joints, the posterior angle Subjects of the left acromion process, the left posterior superior iliac Thirty-nine informed participants with low back pain were spine (PSIS) and the left anterior superior iliac spine (ASIS). recruited to two study groups and were categorized in either Anterior, posterior, and lateral photographic slides were chronic or acute low back pain groups. Twenty subjects with taken in a relaxed upright standing position from a fixed no history of low back pain were recruited to a control group. distance with a horizontal calibration scale in view and with Participants in all groups were in the 18 to 46 year age the appropriate surface markers exposed. Subjects were in- group. Subjects were recruited from selected medical institu- structed to stand with their heels against a line marked on tions and a university campus. the floor, which was either parallel or perpendicular to the Participants in the chronic group had low back pain of camera as appropriate. Patients were then seated in an up- a continuous or recurrent nature for more than 6 months. right position on a backless stool. The stool height was ad- Participants in the acute group had low back pain for less justed so that their feet were supported and their thighs than 6 months and before this episode did not have low back (greater trochanter to centre of the knee joint) were parallel pain for the past 12 months. All low back pain patients were to the ground. Lateral and anterior slides were then taken in diagnosed to have one of the following: degenerative disc the sitting position. All slides were rear projected onto a disease with or without herniation, mechanical back pain ground glass screen for making measurements. (facet joint syndrome, muscular injury, ligamentous injury), The degree of lumbar lordosis was measured using the or osteoarthritis of the spine. method described by Flint. 33 Using the lateral photograph, Participants in the control group had no history of low lines were extended from the T12 and L5 pointers and the back pain for the past year and never had low back pain angle ((L) at their intersection was recorded (fig 1). Thoracic lasting longer than 1 month. kyphosis was measured using an extension of Flint's 33 Subjects with a self-reported diagnosis of spondylolis- method for lumbar lordosis. Using the lateral photograph, thesis, spondylolysis, myofascial pain syndrome, sacroiliac lines were extended inwards from the C7 and T12 pointers, joint problems, osteoporosis, scoliotic deformity, pregnancy, and the angle ((T) at their intersection was recorded (fig 1). metabolic diseases, or neoplasm were excluded from the Validity of this technique has been documented by Flint 33 study. In addition, individuals with congenital deformities, and the correlation between X-rays and this measure was spinal surgery, or recent general surgery (last 12 months) significant at the 0.01 level for the curve between L2 and were also excluded. L5S1. Head position was also measured from a lateral photo- Procedure graph using a method similar to that described by Braun and The measures of posture used for standing and sitting Amundson. 34 The angle ((H) between the tragus-C7 line and postural analysis included lumbar lordosis, thoracic kypho- horizontal was then calculated (fig 2).