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Improving the posture and health of your older clients

We can all relate to our mothers telling us to “sit up” and “don’t slouch” when we were kids but never really took it to heart. Now research is indicating that mom actually did know best about posture. Considering how often we use our mobile phones and computers, upper cross syndrome with forward head posture and rounded shoulder has become the norm for many of us. Recent U.S. Census data finds that 71% of adults own a smartphone while 83% have a laptop or desktop computer. (1) This translates to nearly 3 hours of computer usage a day for the average adult. (2) Short term effects of poor posture can include headache, neck pain and back pain. However, the longer term sequelle can become a matter of life and death since it is estimated that 20% to 40% of elderly people have an accentuated thoracic posture.

The known complications of abnormally accentuated thoracic curvature, or hyperkyphosis posture, includes poor respiratory function, decreased balance and a loss of ones ability to perform activities of daily living (ADL) to name a few. In a 2009 study researchers found thoracic hyperkyphosis was a predictor of an increased risk of death in elderly women, leading them to conclude, “hyperkyphosis should be recognized as a geriatric syndrome.” (3) Additionally, an earlier study by Huang and colleagues found that modest hyperkyphosis increased the risk of vertebral fracture over the next 4 years. (4)

In the elderly, falls can have serious consequences resulting in a loss of one’s independence. Kado et al. showed that hyperkyphotic posture may identify a risk factor in men for injurious falls. More specifically, the authors go on to state that “the simple clinical observation of being unable to lie flat could potentially aid in identifying older men at high risk for future injurious falls, so that targeted interventions can be made.” (5)

One concomitant factor regularly identified with thoracic hyperkyphosis is a forward head posture, which is directly related to respiration. Szczygiel and colleagues reported that a change in head posture decreased respiratory movements most notably of the lower chest requiring increased respiratory movement of the upper chest and accessory neck muscles. (6)

The loss of ADL function is also of concern as many countries are experiencing a declining birth rate resulting in a disproportionate ratio of young people to care for an aging population. This was most notably pointed out in a study by researchers in Japan who monitored the ADL function in people age 65-94 over four and a half years. They concluded that attention needs to be paid to the inclination of spinal posture to identify elderly people at high risk for becoming dependent on their ADL needs. (7)

In 1916 the Journal of the Osteopathic Association defined normal posture as “an equilibrium in which there is no strain on the ligaments and a minimum expenditure of muscular force over and above the energy called muscle tone, a nice balance in which the centre of gravity passes in the correct relation to the bony structures.” (8) Since then, there have been various definitions of normal posture all concluding without proper sagittal alignment the spine and body will undergo compensatory changes both physically and mechanically.

There are several studies showing a relationship between hyperkyphosis and weak back extensor strength. This provides a great opportunity to work with and help this demographic improve their strength, and ultimately their quality of life. Prior to initiating an exercise program, it is important to have your client properly evaluated by a medical professional to rule out any underlying conditions including Scheurmann’s disease or other spinal pathologies. (9) Once cleared by their health care provider a simple assessment is necessary for a variety of reasons. (10)

  • Documented assessments are a great way to create a sense of urgency that is sometimes needed to get the client engaged enough to undertake necessary care. Visuals that show them their current state make it easy to illustrate associated risks and explain how you will help them.
  • Regular follow up assessments will help clients to understand their progress. Seeing an improvement in posture or strength can help them ‘celebrate’ small wins and further commit to their program.
  • Re-assessing is a great chance of re-connecting and will allow you to reflect on their progress together and discuss future goals. Plus, making the client aware of upcoming assessments can create stronger accountability and program adherence.
  • Find assessments that work for you (and your client), are relatively easy to execute and be consistent when using them

Utilizing the NASM guidelines for assessing posture, note your upper and lower cross findings (11). A picture of your clients’ posture can often be more powerful than just providing an explanation. This can be done easily with your smart phone or with more advanced digital assessment app such as PostureScreen Mobile. However, it is always prudent to get the clients consent prior to any digital assessment.

Once you have the baseline assessment established, a good starting point is exercises focusing on thoracic extension, shoulder flexion, scapular strengthening and hip extension. Katzman and colleagues showed these types of exercises performed daily for 12 weeks produced an 11% improvement in kyphotic posture of women 65 years and older (12). Below are guidelines to performing some of these exercises.

Warm-up Exercises

 

Shoulder Rolls

Begin by standing tall, shoulders should be back and head up. While maintaining good posture, lift the shoulders upwards without rounding shoulder forward. Then lower shoulder downward while squeezing scapula together, then releasing back to neutral again without rounding forward. Perform 2 sets of 8 repetitions.

 

 

 

 

 

Brugger’s Scapular Retraction

Begin by standing tall, shoulders should be back and head up. Bend elbows to 90 degrees and keep elbows near sides. While maintaining good posture, draw shoulders back squeezing shoulder blades together. A stretch may be felt in chest and front of shoulder. Do not allow shoulders to rise upward. Perform 2 sets of 8 repetitions. 

Exercise Routine

Perform 3 sets of 8 repetitions daily.

 

 Head Retraction

Begin seated, or standing, looking forward with shoulders back with good neutral posture. Attempt to draw head directly backwards. Maintain level head position. Do not tilt head up or down. Hold for two seconds. Return to start position and repeat.

Standing Rows with Resistance Band

Begin by standing tall in good posture with shoulders back. Anchor resistance band around door handle, grasping each end with arms slightly extended. Activate core muscles. Pull elbows back just past the body with a rowing motion. Simultaneously squeeze the shoulder blades and contract mid-back muscles. Return to start position. Do not round shoulders forward or let them rise during the exercise.

Bird Dog

Begin on your hands and knees with the head and back in a straight position. Hands should be under the shoulders, hips directly above knees (can place a folded towel under knees for comfort). Gently tighten abdominal muscles. Raise one arm to shoulder level as opposite leg simultaneously lifts off floor, extending to hip height. Pause momentarily. Return to start position and alternate sides. Maintain a straight spine position, not allowing the hips to twist or rotate. Do not hyper-extend through the low back when extending leg.

Prone Hip Extension

Begin lying face down on the floor. Bend elbows with hands under forehead or chin. Gently tighten abdominal muscles. Keeping leg straight, lift it upward off the floor 6 inches. Squeeze glut muscles to emphasis contraction. Slowly return to start position and repeat on opposite leg.

Cool Down Stretches

Standing Hip Extension and Calf Stretch

Begin standing with leg to be stretched extended behind body. Leg should be straight with heel on the ground. Use a counter or the back of a sturdy chair (without wheels) for support. Slowly lean forward, putting weight onto front leg while maintaining straight leg and heel-to-floor contact. A gentle stretch should be felt in the upper calf muscle. Hold for 20 seconds and then repeat on opposite side.

 

Overhead Stretch

Begin seated or standing. Raise right arm up over the head and stretch toward the opposite side. Hold for 20 seconds and repeat on other side.

Considerations for exercise programming
It is of utmost importance that clients with any medical history be cleared by their healthcare professional before starting an exercise program. If the client has completed physical therapy, you can use the exercises that they have learned during their sessions as a good starting point and base for progression or refer to the NASM Essentials of Corrective Exercise book for recommendations. 

General Strength Training Guidelines for Adults age 65 and older (13, 14)

  • Briefly warm-up prior to EACH exercise.
  • Do at least one set of 8-10 repetitions of each exercise, to the point of fatigue.
  • Increase resistance when 10-15 repetitions can be completed using proper form.  Typically use increments of 2-5% of weight or 2-5 pounds.
  • Perform both the lifting and lowering phases of the exercise in a slow and controlled manner. Remember, never sacrifice form for more weight.
  • Perform exercises through a full range of motion.
  • Maintain a normal breathing pattern throughout the exercise.

As with all exercise programs, long-term adherence and exercise execution on a regular basis are important to achieve satisfying results. After your clients have mastered the movements and are able to maintain good form, you can provide them with short at-home protocols that they can do without equipment to establish regular activity patterns and thus increase their results.

Download the geriatric exercise program handout here.

See Dr. David Cruz live and in person at NASM Optima 2017 as he presents: Surprising Health Risks Caused by Bad Posture and How You Can Help Your Clients Avoid Them

 

 

 

References:

  1. Thom and Camille Ryan, “Computer and Internet Use in the United States: 2013,” American Community Survey Reports, ACS-28, U.S. Census Bureau, Washington, DC, 2014.
  2. Bosomworth, D. Mobile Marketing Statistics 2015. Retrieved from: http://www.smartinsights.com/mobile-marketing/mobile-marketing-analytics/mobile-marketing-statistics/
  3. Kado, D., Lui, Li., et al. 2009. Hyperkyphosis Predicts Mortality Independent of Vertebral Osteoporosis in Older Women. Ann Intern Med. 150:681-687.
  4. Haung, M., Barrett-Connor, E., et al. 2006. Hyperkyphotic Posture and Risk of Future Osteoporotic Fractures: The Rancho Bernardo Study. Journal of Bone and Mineral Research. 21(3):419-423.
  5. Kado, D., Haung, M., et al. 2007. Hyperkyphotic Posture and Risk of Injurious Falls in Older Persons: The Rancho Bernardo Study. Journal of Gerontology. 62A(6): 652–657.
  6. Szcxygiel, E., Weglarz, K., et al. 2015. Biomechanical influences on head posture and the respiratory movements of the chest. Acta of Bioengineering and Biomechanics. 17(2):143-148.
  7. Kamitaini, K., Michikawa, T., et al. 2013. Spinal Posture in the Sagittal Plane Is Associated
With Future Dependence in Activities of Daily Living:A Community-Based Cohort Study of Older Adults in Japan. J Gerontol A Biol Sci Med Sci. 68(7):869–875.
  8. The Journal of the American Osteopathic Association. Contents from September, 1916. The American Osteopathic Association, New York, N.Y.
  9. Kado, D. 2009. The rehabilitation of hyperkyphotic posture in the elderly. Eur J Phys Rehabil Med. 45:583-93.
  10. Aprea, F. Why regular assessments can drive outcomes – clinically and for your business. 2017. Retrieved from: https://www.webexercises.com/2017/04/reasons-why-you-should-do-regular-assessments.html
  11. Clark, M., Lucett, S., Sutton, B. (2014) NASM Essentials of Corrective Exercise Training. Burlington, MA, USA: Jones & Bartlett Learning.
  12. Katzman, W., Sellmeyer, D., et al. 2007. Changes in Flexed Posture, Musculoskeletal Impairments, and Physical Performance After Group Exercise in Community- Dwelling Older Women. Arch Phys Med Rehabil Vol 88.
  13. Nelson, M., Rejeski, J., et al. 2007. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116:000–000.
  14. Tompson, P., Arena, R., et al. 2013. ACSM’s New Preparticipation Health Screening Recommendations from ACSM’s Guidelines for Exercise Testing and Prescription, Ninth Edition. American College of Sports Medicine. American College of Sports Medicine. 12(4):215-217.
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The Author

David Cruz, DC, CSCS, FMS, SFMA

David Cruz, DC, CSCS, FMS, SFMA

Dr. David Cruz practiced as a sports chiropractor for 18 years treating athletic injuries, from weekend warriors to professional athletes. He received his bachelor’s of science degree in athletic training and has completed graduate course work in kinesiology. He is a Certified Strength and Conditioning Specialist (CSCS) as well as having both FMS and SFMA certifications. The combination of his background in sports medicine and interest in technology made him passionate about bringing these two worlds closer together, resulting in the foundation of his company WebExercises in 2005.
WebExercises is an end-to-end solution for exercise rehabilitation professionals and is currently integrated with several EHR companies. In addition to WebExercises.com, Dr. Cruz is co-founder and partner of two other software businesses within the health care and technology industry.