Dear D….

My reply to a support group post from a woman, who was prescribed muscle relaxers and physical therapy. This combination didn’t help after 2 weeks, so her doctor stopped both and prescribed Celebrex instead.  Celebrex seemed to help but she was concerned over the side effects her friends had experienced, including kidney damage from long term use.

 

Dear D…,

Celebrex helps but it is not a long term solution because of potential side
effects, which are different for each individual and of course there are the
lucky ones, who never have any side effects. I became allergic to all nsaids
after I was on high dose Celebrex for several months, which I hadn’t been
before. One Celebrex or an aspirin sends me into anaphylaxis.

If you don’t have out-right bony nerve compression in your neck and don’t need
surgery, then the right kind of physical therapy should help you.

It took me years of physical therapy to figure out that a lot of what is offered
by PTs is not the right kind of therapy for neck pain.

The right kind is to start off first with evaluating postural alignment, in
particular upper body alignment, and then begin a program of strengthening
certain muscles, mainly back muscles, and stretching others mainly chest
muscles, so that you can more easily maintain correct alignment of the
upper body. And the consequence of correct alignment of the upper body is
correct alignment of the head and neck.

After that, any other kind of treatment a PT wants to give: heat, ice, stim,
mobilization, traction, or other exercises may help but only short term unless the posture
issue is addressed first.

Posture of the lower body and also posture while sitting and doing daily work is
also important. How you hold your head, which is like a 10 pound bowling ball
perched on a stick of a spine, determines the stress on your neck muscles. Hold
the head out in front of your shoulders all day long and your back neck muscles are
over-worked and become very unhappy. And if you always let your upper back slouch,
the poor muscles that suspend your shoulder blades from your neck cry “uncle.”

If you have a lot of neck joint inflammation to begin with, allow at least 2
months of posture training to see reduced neck pain. My neck had gotten so bad,
that the pain flared with direct neck massage, cervical joint mobilization and
neck traction. A good posture correction program corrected that in 2 to 3
months.

I realize that Fixing Posture First sounds counter-intuitive, but try it, it
might just work for you like it did for me.

Rochelle

Slouched Posture: Efficient or Not?

Inspired by Todd Hargrove’s post at BetterMovement.org: “Is “Efficient” Movement Unsafe?

The Back Extensor Group of Muscles

I remember reading that good posture was the most energy efficient way to stand and sit. But why does it seem to take so much more energy to keep the spine straight than to slouch, especially with fatigue or illness. If energy efficient means using the least amount of energy to perform work then at first glance, slumping with rounded back does seem to take less energy because the back extensors, a large group of back muscles, slack off from straightening the back and let the weight of the upper body hang passively off spinal ligaments and joints. But is the spine well suited to supporting this much dead weight by itself? The short answer is “NO” because the spine has inherent flexibility that allows it to bend when needed for everyday activities. The fact is that by itself the normal spine cannot be both flexible to allow us to bend down to tie our shoelaces and inflexible enough to completely support our bodies. A fused spine can’t bend and therefore doesn’t need stabilization, but a normal, flexible spine does need the stabilization that is provided by the balanced action of two antagonistic groups of muscles—the back extensors, which bend the spine backwards (and keep us erect), and the front abdominals which bend the spine forward. For ideal posture the extensors and flexors act in concert to stiffen the spine in as close to a vertical position as the natural curves allow. This is the spine’s most stable and least stressful/damaging upright position and results in even distribution of compressive forces on intervertebral discs.

When the back is excessively rounded forward, discs are unevenly stressed, and over time their outer layer or annulus prematurely develops tiny cracks that cause loss of moisture and disc height, which causes spinal instability, increased pressure on facet joints, bone spur formation and stenosis. A rounded back also causes an imbalance of head and upper body weight. Optimal distribution of body weight is important for our ability to stand upright. Moving around on two legs is precarious to begin with. And if the ten to fourteen pound head juts out in front of the body because the top of the thoracic spine curves forward, and the upper chest and back, shoulder and arms also curve forward, it’s more difficult.

There is already a natural imbalance of weight due to the rib cage chest area extending out front of the thoracic spine,

Balanced(which has a natural kephotic (posterior) curve to counterbalance the rib cage (see balanced posture at left) and this weight imbalance causes a constant forward bending pressure on the spine that must  be resisted for the body to stay upright.

 

 

 

 

With excessive rounding of the upper back, the body must realign itself to keep from falling forward. One of three strategies is used:
Flat_Back

 

1. The pelvis rotates backwards, trying to pull the upper body upright, and pulls both the lumbar and mid thoracic spine flat. But since the upper back and head are still held forward of the torso, and there’s no counter-balancing curving of weight to the back, the entire body leans a little forward, not so much that one would fall over (unless trying balance exercises), but enough to have difficulty flattening the entire back and head against a wall without extending (bending slightly backwards) the back. see Flat Back Posture

Sway_Back1

 

 

 

 

 

 

 

2. The upper torso shifts backwards in a long, rounded curve that is also counterbalanced by the pelvis shifting forwards. See Sway Back Posture.

 

 

 

 

 

Kephotic_Lordotic1

3. The excessively hunched upper back is counterbalanced by the abdomen, which pooches out in front because of an excessive inward lordotic curve of the lower back. Against a wall, the upper back and butt may touch, but there’d be lots of space between wall and lower back. See Kephotic-Lordotic Posture.

 

 

All three strategies/postures produce their share of sore backs and necks.

 

 

 

 

Balanced Posture

Now, getting back to the subject of “Efficient Movement.”  A better definition for “efficiency” would be “The least energy used to achieve the best possible result.”  The back extensors must be engaged to stabilize the spine, so that body weight and other forces are borne with vertebra stacked vertically, one on top of the other and the forces are spread evenly on discs and ligaments. When the back is as straight as possible, given the natural curves,  body weight is close to being balanced around the spine. The vertical black line (the center of gravity) in the posture illustrations, represents equivalence of weight in front of and behind the line. When weight is balanced, posterior muscles like back neck muscles and lower back muscles, as well as hip extensors (hamstrings) (depending on the type of faulty posture) are not over-worked. But also front postural muscles like neck flexors, abdominals and hip flexors are not under-worked and weak.

In Todd Hargrove’s words: “any local gains in energy efficiency from “floppy joints” are more than offset by a general loss of energy efficiency that comes from poor alignment of the bones and inadequate stabilization of the joints….In other words, valgus knees (knees collapse inward), rounded backs, and overpronated feet (foot rolls inward and arch collapses) are not actually energy efficient at all, because they sacrifice the stabilization and proper bony alignment which is the key to efficient movement and posture.” Yes, it feels easier to slouch especially when one is tired or not feeling well. Add a chronic illness, and it seems like there’s little energy left to stand tall with good posture. But it is so worth the effort because the strength and balance of postural muscles is preserved and the chances of postural neck and back pain are greatly reduced.

Examples of Poor Posture

Posted on June 22, 2012 by Rochelle

The Thinker by Auguste Rodin, one of the most recognizable sculptures in Western Culture, is an example of really bad posture. I’ve added the skeleton to show that his rib cage sags and constricts his breathing. His lower back is rounded, which puts excessive, one sided, pressure on the intervertebral discs of the lumbar spine. His posture though, is not the worst  I’ve seen. He doesn’t sit on his lower back like so many  young people. He sits squarely on his sitting-bones or  ischial turberosities.

 

Gwyneth Paltrow is a beautiful woman but tends to have swayback posture. In Duets, a marvelous  movie combining multiple story lines with love and karaoke,  Paltrow exaggerates her poor posture even more to portray a gawky, young innocent, who melts the heart of her long absent karaoke-hustler father, played by Huey Louis.

 

 

 

 

 

 

 

 

 

 

 

 

 Lily Cole, an English model and actress, tends toward a rounded back.

 

 

 

 

 

 

 

 

Myley Cyrus, like many teenage girls, tends to have curved forward shoulders, rounded back, and depressed chest.

 

 

This is approximately what my posture looked like before I realized that slouching had caused my chronic neck pain. Unfortunately, none of the many doctors or the four physical therapists  I went to for help ever mentioned my poor posture as a possible cause of neck pain. One PT commented that my shoulder blades weren’t working right, but he didn’t say why and didn’t give me exercises to fix it. (Or maybe he did but I was clueless at the time. In my defense, I had a debilitating stomach illness, was in a lot of pain and my neck felt so weak I could barely make it to PT sessions. ) Regardless, I’m still amazed and very disappointed that all these professionals could not help me. I had to find my own way.    See fixtheneck.com

Rear and Side View Car Mirrors

A panoramic rear view mirror* became a necessity when my neck muscles were so spasmed I could barely turn my head.  To this day, I still use a panoramic rear view mirror, because it feels wrong not to.  Why don’t all cars come so equipped?  They have loads of new technology and safety equipment,  front and side airbags, hands-free blue tooth, GPS, T.V. and wired for mobile everything.  A simple panoramic rear view mirror seems a no-brainer. (However, when I couldn’t turn my head at all, I didn’t dare drive even with the panoramic mirror; it was just too dangerous.)

*Auto parts stores have inexpensive, light-weight panoramic rear view mirrors that fit over the existing rear view mirror.

To help with seeing cars  in the blind spot, I use a little stick-on convex mirror in the corner of the driver’s side-view mirror.  This was another necessity when my neck was so stiff and now I still use it.

Fitness Classes

I don’t know how common this is, but many of the stretching/strengthening exercises in my fitness class at a local senior center (yes, I am that old.) involve some kind of bending-forward . This is particularly true of the mat exercises, which include crunches (modified sit-ups) for strengthening abdominals, several types of jack-knife type positions (sitting while leaning backwards with legs extended and raised) while holding weights in various positions,other variations of sit-ups and also the bending-forward, reaching-for-the-toes exercises for stretching hip extensors (hamstrings), and even though the instructor says to keep the back straight many of the students hunch their upper backs to reach their toes, which elongates/weakens the thoracic back extensors which worsens the hunch  And too many crunches can worsen sway back posture. Meanwhile strengthening back extensors, the muscles that pull our backs erect, is ignored.  If exercises only target front abdominals for strengthening and end up stretching opposing back extensors, that is a prescription for worsening hunched posture. More bending forward exercises to strengthen abs increases the tendency for the body to bend forward all the time. After all, isn’t that what these exercises are training the body to do?  For healthy balanced posture, at least equal attention must be given to back extensor strengthening.  And for those who already have hunched posture, more attention must be given to back extensors, and depending on the type of faulty posture, only particular abdominals may need to be strengthened and perhaps abdominal strengthening is not needed at all, in fact may be counter-productive as in flat back posture.  For a senior population already tending toward hunched posture because of increases in chronic illness and age-related decline in bone density (a risk for wedging of vertebral bodies and compression fractures with bending forward exercises), a balanced muscle strengthening program is even more important.

The rest of the class, which includes 30 minutes of aerobics is enjoyable. Doing the steps to “up beat” music keeps participants coming back and that is  important. I intend to stay with the class especially for the step aerobics, which gets the heart pumping but not excessively. There is no pressure to do all the exercises and I can opt out of the exercises that are counter to my posture type (flat back).

 

Tai Chi classes: Tai Chi is done slowly, mindfully, with arms and legs coordinated and both moving throughout the movements. Learning it well takes balance, understanding the logic and flow of the movements, and sensitivity to the proprioceptive senses — all of which is very challenging,

From the aspect of improving posture, you’d think that good posture would come automatically with Tai Chi practice, however, from what I saw in this Senior Center Class, Tai Chi by itself does not improve posture. Over half the participants have a more kephotic upper back than is healthy.  Perhaps if there were mirrors on all the walls or practices were video-recorded, and people actually saw themselves  maybe they’d straighten up. But how likely is that?

Two articles of interest for those considering back surgery

A New England Journal of Medicine article–Surgery versus Prolonged Conservative Treatment for Sciatica, Conclusions: “The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery.”
The Journal of Bone and Joint Surgery–Surgical Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis, Conclusions: “Compared with patients who are treated nonoperatively, patients in whom degenerative spondylolisthesis and associated spinal stenosis are treated surgically maintain substantially greater pain relief and improvement in function for four years.”

Yoga

As a teenager I dabbled in it, but either injured myself as when I tried a yoga headstand and strained my neck, or began wondering what all that extreme twisting and bending was doing to my joints and ligaments. I watched my dad, a student and teacher of Hatha yoga, who did the positions much better than I could. He also had a lot more determination than I, maybe too much. He would remain in a headstand propped against a wall for quite some time—his face turning bright red. Later I wondered if that had something to do with the Alzheimer’s that overtook him in his late 60s. (Or was it head trauma from boxing as a heavyweight on his college team? No one else in his family ever had Alzheimer’s.) Anyway, he finally did stop doing the extreme lotus because he figured it caused the painful phlebitis (a blood clot in a deep vein of a lower leg) that swelled his lower leg. The lesson here being: don’t do yoga to extremes.
But mostly I’ve heard good things about Yoga from friends. However, a recent article in the New York Times, How Yoga Can Wreck Your Body, discusses the small but growing numbers of serious injuries to the lower back, shoulder, knee and neck. Glenn Black, a well known New York instructor states that injuries occur because students have underlying weaknesses that need to be addressed first. Also mentioned is Yoga Instructor, Carol Krucoff, who tore a hamstring muscle while being filmed doing Kitchen Yoga for a national TV show. See Insight from injury: If the practice of hatha yoga was meant to heal, why are so many yogis getting hurt? Instructor Glenn Black in another interview, Yogi Glenn Black Responds to New York Times Article on Yoga, lists pinched nerves in the neck, low back tightness, injuries to hips, knees and shoulder problems and also which yoga poses to avoid. And most disturbing of all:

EF: You now have a spinal fusion and screws in your lower lumbar spine to stabilize herniated discs and spondylolisthesis. How did your own yoga injuries come about?

Glen Black: Extreme back bends, and twisting coming up from my hands on my ankles. I overstretched my ligaments and destabilized my spine. 

But any sport or activity done to extremes can cause injury. See: Practicing Safe Yoga — 5 Tips to Avoid Injuries by Eva Norlyk Smith, Ph.D.

Do Glucosamine and Chrondroitin help arthritis?

Well designed studies say no (see “Glucosamine and Chondroitin for Arthritis: Benefit is Unlikely” by Stephen Barrett, M.D. at Quackwatch. In brief: the largest and best study, the Gait or Glucosamine/Chondroitin Arthritis Intervention Trial, showed virtually no pain relief and an extension of the study showed no significant structural benefit, defined as slowing of the narrowing of the joint space in the knee). Another study specifically studied 250 adults with chronic low-back pain and degenerative arthritis for a year. Half received glucosamine and half placebo with no difference between the two. A more recent study involving 662 GAIT patients looked at glucosamine and chrondroitin sulfate, either separately or combined, and celecoxib (Celebrex) as well as a placebo. No statistically significant differences were found among the groups.
I myself took Glucosamine and Chondroitin for several months without positive effect, but then Celebrex at that time didn’t help either. There are people I know who claim they have been helped, especially by formulations with MSM, but it’s no miracle cure. So far there don’t seem to be any serious side effects of these supplements, but since supplements in general are not regulated, I’d be careful and also ask a doctor for advice. For a possible mechanism of action for glucosamine see “Food Intolerances: The Controversy Over Gluten Grains and Nightshade Plants: Do They worsen Arthritic and/or Intestinal Inflammation?

Neck Pain From Using Cell Phones, Tablets and Laptops

My son, a personal trainer, told me that one of his clients was complaining of neck pain. He asked her how often she used her new Kindle Fire. It turned out that excessive tablet use coupled with poor posture was the source of her pain.

When using a cell phone for text messaging, anchor your upper arms close to your body and bend your elbows to raise the phone closer to your face. Then lower your eyes, instead of tilting the head down, to see the screen. Avoid bending the neck forward and down; if you still must tilt your head, use the top-most “hinge” joint of the neck. But do try to have your arms and eyes do most of the work.

A handheld tablet with keyboard seems like it would be very awkward to type with (needs thumb-typing or one-handed typing). So a tablet is probably placed on a surface for that. My son says the Apple Ipad has dictation capability; maybe typing is not so necessary. Then there’s the stylus, a one handed implement for note-taking. [update: one needs to speak very clearly for Ipad dictation to be accurate (good speech therapy for those who need it!). My son bought a case that tilts the Ipad up so he doesn’t need to tilt his head down as much. He also says a case is available that comes with a separate keyboard and also elevates the Ipad. Essentially the Ipad becomes a desktop.]

Typing on a laptop rather than a tablet should be easier on the neck, as long as it is on a surface like a table top, which it seems most people do. But still the monitor cannot often be raised to comfortable eye level so see people bending their necks down all the time. As with cell phones, it is better to roll the eyes down. Better still would be if the laptop screen could be separated and hung at eye level. (Do any laptops come with separatable screens?). For now I am sticking to my desktop computer. At least the monitor can be adjusted to a comfortable height, which for me is just below eye level, so I can see it in the reading part of my eyeglass lenses without tilting my head up. (First I adjust my chair height so my feet rest firmly on the ground and my lower legs are perpendicular to the ground. If the monitor needs to be higher, I use a large book or two to raise the monitor further.)

For an informative video on improving sitting posture to avoid neck and shoulder pain due to prolonged desk work, computer and mobile device use; see Sitting At Your Computer on Dr. Robert Kelty’s Chiropractic Wellness Center Website

 

Habit Formation, Exercise and Posture

As much as possible, the brain converts repeated actions into automatic routines or habits in a process called chunking. Once chunked, behavioral routines require minimal attention or mental energy to perform. All that’s needed is a cue (or trigger) that switches the brain to autopilot and starts the routine; and then at the end, a reward tells the brain if this particular routine (may be physical, mental, or emotional) is worth doing again. The cue and the reward become associated so that when the cue is present, a craving to perform the sequence emerges. Cues and rewards can be obvious; e.g. doing the grocery shopping every Saturday morning (cue) and afterwards buying a coffee at Starbuck’s (reward). Or not so obvious: washing up before bedtime (cue) triggers toothbrushing, and afterwards the feeling of a clean mouth serves as the reward. Some cues and rewards are so slight that one may hardly be aware of them, but our neural systems certainly are.

Trying to change a habit sequence once it’s triggered is difficult because the conscious brain is not actively involved. One approach in particular seems to help; a study on exercise habits showed that when participants were educated about habit formation and then asked to identify cues and rewards that might increase participation in exercise routines, they exercised twice as much as those who only received lessons on the importance of exercise. Simple cues seemed to be most effective. For example, I put a pedometer (a Fitbit) in my pocket after dressing in the morning (the cue) and take one walk then. Checking how many steps are recorded, gives me a little rush of satisfaction (the reward). (A second walk is cued by my dogs, who won’t leave me alone until we head out the door in the afternoon.)

For an interesting article on habits see the New York Times Article, How Companies Learn Your Secrets (they want to know when a life changing event, such as impending marriage or childbirth will occur, in order to get a headstart sending out advertising. Otherwise one’s spending habits aren’t very open to change and advertising has minimal effect. This article is based on the book by Charles Duhigg, “The Power of Habit: Why We Do What We Do in Life and Business

So how can cues and rewards be applied to improving posture? My experience has been that the feeling of slumped posture can become a cue, and when I become aware of it, I tighten and straighten my mid-back, which lifts my chest and gives me a feeling of release from chest constriction (a reward) and I take a deep breath. Then I do a rep of the Fix the Shoulder Blades Exercise, during which I often remember how much better my profile looks (even when I’m not anywhere near a mirror) and how good my neck feels now versus how miserable it used to be (more rewards). Finding and appreciating those rewards required that I become more aware of how my body looks (especially from different points of view), and also more sensitive to how my body feels, not just pain, but muscle tension, joint position, limitations imposed by poor posture, awareness of shoulder blade anchoring, spine position, posture during movement etc., or everything that comes under the classification of kinesthetic senses. Sometimes I wonder why I didn’t naturally have those sensitivities when I was younger. Perhaps it was my sedentary life. And perhaps also because poor posture develops so slowly there’s never enough difference to notice; and meanwhile the body memory of good posture is slowly lost. As well there’s often little feedback from other sources of information, such as visual (generally only face forward view in a mirror is available and that doesn’t help in seeing the entire body’s alignment), or comments from family and friends (who often don’t want to say anything upsetting, even my mother had stopped criticizing), or advice from medical professionals, fitness professionals and physical education teachers (of all the many I had contact with, none ever said anything about my posture). And perhaps also, poor posture itself, and any pain from poor posture, deadens sensitivity to body state. Is it any wonder that a person’s posture seems to be a relatively unchanging part of his or her physical appearance, except to slowly get worse with age? In order for a person to improve posture, an epiphany of some sort is needed. And once some improvement has been experienced, the body becomes more sensitive to what a healthy postural state feels like, and strives to maintain that state.

However, there is a matter of backsliding into poor posture, and I do find myself slouching, but only when working long hours at the computer, not when standing, walking or other more physical activities. The good thing is though, that I’m more aware of slumped posture, and I put more effort into correcting it. So why is slumping more likely at the computer? Perhaps because computer work takes a great deal of mental energy, and the mind and body tires quickly. And being tired means less energy for the back extensors, which are the critical muscles keeping our backs erect against gravity. Our body structure doesn’t help either. The spine tends to bend forward because the bulk of body weight, is in front of the spine. The thoracic spine, in particular, supports the ribcage and attached muscles and organs, which are a major part of the body’s mass. No wonder the thoracic spine, which naturally has a rounded, kephotic curve, tends to curve even more forward under that weight if the back extensors aren’t kept strong.

Ultimately, maintaining good posture is a continuous challenge, but it is a challenge that can be won, if one becomes aware that it feels so much better (the reward) than slumped posture. The reward is even greater if one has suffered years of pain from it.