Lower Back pain



lower Back pain syndrome



FICURE 18. Sitting postures common to Eastern cultures

spine and enters upon the anterior aspect of the femur. As the hips
extend to assume the erect posture, extension at the hip joints causes a
simultaneous forward traction on the lumbar spine via the psoas attachment
causing anterior convexity or lordosis


The upright adult exhibits balanced physiologic curves. Static spinal
configuration can be considered "good posture" if it is an effortless,
nonfatiguing posture, painless to the individual who can remain erect
for reasonable periods of time, and present an aesthetically acceptable
These criteria of normalcy must be considered in ascertaining the
cause of painful states and the factors demanding correction. Significant
deviations from physiologic static spinal curves can cause discomfort
and disability.
There are many factors that influence adult posture, but there are
three factors that supersede all others in their prevalence and frequency.
(1) Familial-hereditary postures, such as marked dorsal
kyphotic spine, a noticeable "sway back," etc.; variations in ligamentous
laxity, muscle tone, and even psychologic motor drive have a

             FIGURE 19. Body engineering of stance
performed with broad, heavier parts at the toP
situated upon a narrow base

familial-hereditary component. (2) Structural abnormalities influence
posture. Such abnormalities may be congenital or acquired, may be
skeletal, muscular, or neurologic, and may be static or progressive.
Postural defects can occur as the result of neuromuscular diseases, such
as cerebral palsy, parkinsonism, and hemiplegia. The influence on the
postural structures from diseases, such as rheumatoid arthritis and
poliomyelitis, and from peripheral nerve injuries needs no elaboration.
More insidious in its influence and admittedly more controversial in its
acceptance is (3) the posture of habit and training.
Postural influences attributable to a familial or hereditary origin and
postural deviations established b y the external influences of
neuromuscular, articular, or bony pathology can usually be established
by correct history, complete physical examination, and specific laboratory
and roentgen-ray studies. Many diseases portray a specific
diagnostic picture that reveals the diagnosis at a glance. The influence

of some diseases on posture may be less clearly defined, but further
study of the effect of disease on posture can produce additional diagnostic
The effect of habit or training on posture presents a study that has its
own sbare of controversy and difference of opinion. Postural training in
childhood by parental control or training by educators in our schools
has a profound influence in laying the groundwork of ultimate adult
posture. Posture is to a large degree habit and from training and repetition
can become a subconscious habit. The subconscious habit of posture
is manifested not only in static posture but to a large degree in
kinetic patterns. Repetition of faulty action can result in faulty kinetic
function and repeated faulty posture patterns can become ingrained
The ordinary upright posture with arms hanging loosely at the side or
clasped in front or behind is universal. Sitting in a chair is not. One
quarter of the human race habitually take, weight off its feet by
crouching in a deep squat at rest or at work (Fig. 18). Chairs, stools, and
benches were in use in Egypt and Mesopotamia 5000 years ago, but the
Chinese used chairs only as recently as 2000 years ago. Before that time
they sat on the ground as do the Japanese and Koreans. The Islamic
societies of the Middle East and North Africa have returned to sitting on
the floor "for cultural prestige."
A deep squat position for work and rest is used by millions of people
in Asia, Africa, and Latin America. The Turkish or "tailor" cross-legged
squat is used in the Middle East and India and in much of Asia. The
practice of crossing the legs or folding them to one side, which was
thought to be assumed by women because of narrow skirts, is found in
cultures where clothing is not worn
Standing is influenced by the use of footwear as well as a complex of
many factors: anatomic, physiologic, cultural, environmental, occupational,
technologic, and sexual
Of interest is the cultural attitude toward posture. Religious concepts
have influenced posture by prescribing periods of kneeling, bowing,
standing, and prostration during worship. Western postural codes have
been relaxed in the course of the past century. Eighteenth-century
chairs with hard seats and straight backs have been replaced by soft
curved chairs or sofas. We still, however, train our children to conform
to cultural norms of posture by verbal instruction
Standard posture is one of skeletal alignment refined as a relative
arrangement of the parts of the body in a state of balance that protects
the supporting structures of the body against injury or progressive
deformity. This was the definition given by the Posture Committee of
the American Academy of Orthopaedic Surgery in 1947
The body is poorly engineered for standing because stance is maintained
with the heavy parts at the top upon a narrow base (Fig. 19

Balance is more efficient with less energy expenditure if none of the
parts is too far from the vertical axis
Posture must also be viewed from the cultural aspects of training,
background, and childhood environment. Parental example is of undoubted
significance in the establishment of accepted normal posture
Competition and example from siblings or classmates will also leave its
mark on the psyche which in turn molds the postural patterns
Posture to a large degree is also a somatic depiction of the inner
emotions. There is no doubt that posture can be considered a somatization
of the psyche. We stand and we move as we feel. Our stance and our
movements mirror clearly to the observer our psychologic inner drives
or their absence. Consciously or unconsciously we assume a pose to
portray OUT inner feelings, and we move in a manner that depicts our
attitude toward ourselves, our fellow man, and our environment. Our
posture is "organ language," a feeling-expression, in fact a postural
exteriorization of our inner feelings
The depressed, dejected person will stand in a "drooped" postural
manner with the upper back rounded and the shoulders depressed by
the "weight of the world carried on his back." This is the familiar bodily
expression when one is too tired to "stand any more of this." Such
posture is a picture of fatigue and becomes in itself a fatiguing posture.
The posture of fatigue places a chronic ligamentous strain upon an
individual and the muscular effort exerted to relieve the strain may be
too feeble to be effectual.
The hyperactive hyperkinetic person will portray his feelings in
posture as well as in the abruptness and irregularity of his movements
The movements of alertness need not be, and in fact usually are not,
those of efficiency and effectiveness. This posture depicts that of the
uneasy aggressor, in combat pose, ready to leap or ready to withdraw in
a defensive crouch. In observing this type of person, the doctor need
not ask his psychologic attitude but should merely observe his sitting
standing, walking, response to questions, and movements during the
interview and examination.
The tall girl may stand slumped. In childhood she wished to be
shorter as were her companions. She stooped "down to their height."
Her counterpart, the short girl, stood "to her full height" to be taller, by
standing on her toes, with her head erect, her chest protruding and her
low back arched. The full-bosomed girl, influenced by teasing or fearing
to lack modesty, sat, stood, and walked with rounded shoulders to
decrease the apparent size of her bosom
All patterns of posture assumed in childhood for real or imagined
results form a pattern that becomes deep seated. The pattern becomes
not only a psychic pattern, but it gradually molds the tissues into
somatic patterns that remain a structural monument to early psychic

molding. When the age of "reason" or realization is reached the posture
is largely fixed in its structural composition and is deeply established in
the subconscious. Without extreme persistent effort to change, that
posture will become a permanent fixture
Feldenkrais' states that improper head balance is rare in young
children except in structural abnormalities. However, repeated emotional
upheavals cause the child to adopt attitudes that ensure safety
This, he claims, evokes contraction of the flexor muscles inhibiting
extensor tone. His analogy to animals is that when they are frightened
they react by violent contraction of all flexor muscles, thus preventing
(inhibiting) the extensor musculature. This prevents running or walking
A similar reaction occurs in newborns as a reaction to the fear of
The attitude of the child from repeated emotional stresses is that of
flexion with concurrent inhibition of the extensors. This attitude in the
upright erect posture becomes one of flexion at the hips and spine with
a forward head posture. This posture becomes habitual and feels "normal
The pain-causing postural pattern can be ascertained by understanding
the deviation from what is considered normal. A full evaluation
of the mechanisms of pain production in the static then in the
kinetic spines will follow, but the exact sites of pain production must
first be determined. When the site of tissue capable of eliciting pain can
be located, the specific movement or positions of the vertebral components
that irritate these tissues can be established. For the evaluation of
the sites in the vertebral column capable of painful reaction we must
return to the jUlictional unit