Recent studies indicate a multimodal approach to adolescent posture corrections proves the traditional chiropractic marketing slogan.
“As the twig is bent, so grows the tree.” Depending on the definition of weak posture, the literature indicates that up to 65% of adolescents aged 10-18 have postural weakness, which is believed to lead to neck and back pain as adults.
The importance of posture in adolescents
The process may be related to plastic deformation (a term this author first heard many years ago from Dr. Monte Greenawalt), which is when soft tissues become inelastic. This is significant for contractile tissues (muscles and tendons), as stiffness leads to damage and dysfunction. According to Safa, “these inelastic behaviors can contribute to the development of clinical disorders, such as tendinopathy and rupture, by changing the macroscale mechanical behavior.”1 Basically, soft tissue stiffness predisposes them to injury and creates abnormal joint position and function.
Inelastic muscles and tendons are vulnerable to damage, such as tears and degenerative tendinopathy. In addition, muscles act in synergistic patterns to allow smooth, coordinated joint motion. If one muscle acting on a joint is inelastic, it affects the arthrokinematics of the local joint as well as the entire kinetic chain, creating abnormal joint alignment and function, which in turn accelerates joint degeneration (arthritis). Conversely, joint misalignments (weak/poor posture) can lead to inelastic soft tissues due to plastic deformation. It is a vicious degenerative cycle that DCs are in a unique position to address, but the question remains: Can we make a lasting impact on adolescents?
Evaluate and assess posture
Posture is more than alignment. It is a complex mechanism involving static and dynamic components. Static posture is easy to assess. Standing, the eyes, shoulders, hips, knees and feet are level and facing directly forward in the frontal plane. The plumb line drops from the ear through the shoulder, hip and slightly anterior to the ankle in the sagittal plane. The spinal curves are balanced, not reduced or in excess. These are the standard postural checkpoints that need to be part of your examination process, regardless of the patient’s presenting complaint.
Dynamic assessment is simply observing the anatomical checkpoints mentioned above with movement. Observe if the static postural weaknesses change with motion. They may become accentuated, stay the same or even become auto-corrected. A majority of the time, a weak posture remains or worsens with loading and motion. Auto correction is more common with movement related to work or sport: movements that have been specifically trained to avoid injury. However, dynamic assessment is perfect to find the inelastic soft tissues that statically present as normal. Dynamic assessments are the cornerstone of a functional assessment because they highlight poor arthrokinematics due to loss of joint motion and imbalanced soft tissues.
Balance in the length/tension relationships of the muscles acting on a joint is necessary for coordinated movement. The “length” component is the elastic properties of the muscles as well as their overall flexibility, and the “tension” component is the strength and elasticity of the muscle under contraction. In addition, coordinated movement (strong dynamic posture) requires this balance to occur in both the agonist and antagonist muscle groups. Therefore, posture affects our patients esthetically (slumped shoulders, uneven hips, turned-out feet, etc.) as well as our ability to move and reduce progressive spinal and joint decay.
Exercise interventions and long-term outcomes
These variables were the impetus for Ludwig and his associates to evaluate if exercise can impact static posture from adolescence to adulthood. He proposed, “the main reason for poor posture is found in poor motor skills and weakness of the supporting musculature, e.g., due to sedentary day-to-day school life,” and that it can, therefore, be improved with exercise.2 His theory is directly related to balancing the length/tension relationships mentioned above.
Generally, Ludwig proposes increasing the strength of the muscles affecting pelvic alignment, specifically retroversion.2 His protocols strengthen the core, rectus abdominus, obliques, gluteus maximus and hamstrings. Stretching and lengthening of the iliopsoas and rectus femoris are included because they also allow a posterior rotation of the pelvis, further reducing any lumbar hyperlordosis. Finally, proprioceptive exercises for body awareness to enable autocorrection into strong posture and optimal static alignment were incorporated.
Ludwig’s protocols emphasized senso-neuromuscular coordination to increase body awareness with both eyes open and closed. A relevant tip he presented was to check for the reliance on visual input for postural control by comparing static posture with the eyes open and closed.2 The degree of change with the eyes closed indicates the degree of CNS involvement in maintaining posture. DCs can restore normal joint motion and stimulate joint proprioception from the feet through to the atlas, which re-boots the nervous system, enabling better outcomes than simply doing exercises with eyes open and closed. CMT with postural correction is part of the multimodal approach.
A chiropractic approach to correcting adolescent posture
The chiropractic postural assessment starts from the feet. We understand the relationship between weakness in the feet and ankles and its impact on the pelvis and spine.3,4 Therefore, in addition to sensorimotor exercises with eyes open and closed, as Ludwig proposes, we look for leg length inequalities and foot posture.3 Since a major proprioceptive center in the body is the subtalar joint, stimulation of the feet with custom, flexible orthotics is a good choice when addressing posture in adolescents. Furthermore, proprioception within the three arches of the foot is essential to achieve optimal results.3,4
Ludwig’s study incorporated supervised exercises two hours per week, and the participants were allowed to participate in youth sports.2 They were followed for six years, from 14 to 20 years old, and the control group consisted of peers who did not receive the supervised exercise instruction and were allowed to participate in sports if they so chose. His findings indicated that postural improvement can be attained and maintained over time. However, the best longterm outcomes were found with continuous training. An interesting finding was that sensorimotor training of postural awareness was more effective with eyes closed.
Final thoughts on adolescent posture assessment and correction
The chiropractic model of posture correction has merit. We address the entire body from the feet to the head, ensuring each joint is properly aligned and functioning well. We incorporate a truly multimodal approach of adolescent posture adjustments, exercise, orthoses and lifestyle changes to affect long-term correction so the twig is straight and so shall the tree grow.2
DONALD C. DEFABIO, DC, DACBSP, DACRB, DABCO, teaches relevant rehab, CCSP/DABCO to rehab Diplomate seminars throughout the U.S. His ebook, The Six Keys to in-Office Rehab, is available free on his website, DeFabioDifference.com. His protocols can be found on his YouTube channel, which has more than 41,000 subscribers. For questions, to schedule a presentation and to register for his workshops, reach him at defabiochiropractic@gmail.com.
References
- Safa BN, et al. Evaluating plastic deformation and damage as potential mechanisms for tendon inelasticity using a reactive modeling framework. J Biomech Eng. 2019;141(10):1010081-10100810. PubMed. https://pubmed.ncbi.nlm.nih.gov/31004138/. Accessed July 19, 2024.
- Ludwig O, et al. Targeted athletic training improves the neuromuscular performance in terms of body posture from adolescence to adulthood – long-term study over six years. Front Physiol. 2018;9:1620. https://doi.org/10.3389/fphys.2018.01620. Accessed July 19, 2024.
- Banwell HA, et al. Paediatric flexible flat foot: How are we measuring it and are we getting it right? A systematic review. J Foot Ankle Res. 2018;11:21. PubMed. https://pubmed.ncbi.nlm.nih.gov/29854006/. Accessed July 19, 2024.
- Pabón-Carrasco M, et al. Randomized Clinical Trial: The Effect of Exercise of the Intrinsic Muscle on Foot Pronation. Int J Environ Res and Public Health. 2020;17(13):4882. https://doi.org/10.3390/ijerph17134882. Accessed July 19, 2024.
