Flatback Posture

What is Flat Back Posture?

Flat back posture is when your lower part of back flattens out, losing it’s normal curve in your spine and tipping your pelvis backward.

• The spine has a natural curve. It has two curves forming an “S” like shape. When you have flat back syndrome the spine loses the lower curve and becomes flat. This causes the spine to become imbalanced and the patient tends to lean forward.
• If you have flat back you may have trouble standing up straight or having constant back or leg pain. The Flatback syndrome may develop due to degenerative disc disease, compression fractures, or ankylosing spondylitis.

Anatomy of the spine :

To Understand Flat Back Posture, You must understand the anatomy and function of the spine. The spine is a column of 24 moveable bones called vertebrae that are connected to one another by ligaments. The bones are separated by discs, which act as shock absorbers and give the spine flexibility. Each vertebra has a three-joint complex with a large disc in the front and two facet (pronounced fah-CETTE) joints in the back. This strong, tripod design keeps the bones connected and aligned, one on top of the other, while allowing our spine to bend and twist.

Spinal Curvatures:

The human spine has natural curvatures. When you look at the back from behind, the spine should be straight and centered over the pelvis. However, when you look at the spine from the side, the curves are designed to maintain balance as the spine is behind organs in the chest and abdomen. The spine has two alternating curves to create an “S” like shape. In the neck and low back there is normally an inward curvature or sway back known as lordosis. In the thoracic spine and sacrum, there is an outward curvature known as kyphosis or hunchback. These curves normally balance out each other so that when the patient stands they are well balanced with their head straight above their hips when viewed from the side. Standing in this position minimizes the effect of gravity and allows the patient to stand with the best posture and use the least energy when moving or walking.

Definition:

Flat back syndrome is an abnormal condition where the spine loses its natural low back curve to become flat. The spine becomes imbalanced and the patient leans forward.

Introduction:

Patients with flat back syndrome typically notice trouble standing upright or have ongoing back or leg pain. Symptoms usually worsen as the day goes on and the patient feels they lean further and further forward the longer they try to stand upright. The severity of the symptoms usually depends on the amount of curvature present and difficulties with standing erect.

In patients with flat back syndrome, a loss of normal lumbar curvature causes an imbalance of the spine. The patient’s head begins to lean forward, away from the body and they may have trouble standing upright. This imbalance can cause muscle fatigue and pain.

Causes of flatback posture:

Today, the term flat back syndrome has been broadened to include any patient with a decrease in lumbar lordosis causing symptoms. As such, flat back syndrome can occur as a result of any condition that shortens the front portion of the spine, causing the patient to lean forward. The flat back syndrome may develop as the result of the following causes: Degenerative Disc Disease, Lumbar Post Laminectomy Syndrome, Compression Fractures, and Ankylosing Spondylitis.

Degenerative Disc Disease: For some patients, progressive degeneration of the intervertebral discs or the shock absorbers of the spine may lead to a loss of height in the front part of the spine. As discs degenerate the spine begins to lean forward and lumbar lordosis decreases. The patient may develop pain as a result of the degenerative disc disease or as a result of the spinal imbalance.

Lumbar Post Laminectomy Syndrome: Lumbar flat back syndrome may develop in patients previously treated with a laminectomy or other lumbar surgery to decompress the spinal nerves to treat stenosis. These procedures can lead to a decrease in lumbar lordosis and in some cases spinal instability.

Vertebral Compression Fractures: Compression fractures are often the result of weak spinal bones due to osteoporosis. A fracture can lead to loss of height of the bone in the thoracic and lumbar spine. This may occur in one bone or in multiple bones throughout the spine, resulting in flat back syndrome.

Ankylosing Spondylitis: Ankylosing spondylitis (AS) is a chronic inflammatory disease that causes stiffness and arthritis throughout the entire spine. Some patients with AS notice an increasing forward posture of the spine, including an increase in thoracic kyphosis or a decrease in lumbar lordosis. This can lead to symptoms of lumbar flat back syndrome.

Symptoms of Flat Back:

In addition to the appearance of their backs, persons with flatback syndrome may also have:

• A sensation of falling forward
• Chronic pain in the back muscles
• Difficulty with certain daily activities
• Fatigue
• Stooping at the end of the day

Many patients with a significant flatback deformity require a cane or a walker to assist them when walking because they are stooped forward and their weight is not centered over their pelvis and legs. The condition can be a source of significant pain, disability, and frustration.

• Forward head posture: The head is poked forward.
• Rounded shoulders: The shoulders are slouched forwards.
• Flat thoracic spine: Lack of upper back natural curve (Thoracic Hypokyphosis)
• Flat lower back: Lack of lower back natural curve (Lumbar Hypolordosis)
• Posterior pelvic tilt: The pelvis is rotated backwards.

a) Flat thoracic spine:

This is where there is a loss of natural curve (kyphosis) in the upper back.

The thoracic spine is locked into an extension.

Cause: This occurs when the thoracic spine attempts to position the shoulders and head (which are generally slouched forwards in most people) into a more upright position.

Muscles responsible:

• Spinalis thoracis
• Iliocostalis thoracis
• Longissimus thoracis
• Posterior intercostals

b) Flat lumbar spine:

This is due to a Posterior pelvic tilt.

This is when the pelvis is rotated backward.

Cause: Sitting with a slouched posture.

This leads to an imbalance of the forces around the pelvis causing a net force to tilt backwards.

Muscles responsible:
Tight/overactive:

• Hamstrings
• Abdominals
• Gluteal muscles

Weak/inhibited:

• Lumbar paraspinals
• Hip flexors

How Diagnosis is done in Flat Back?

The diagnosis of lumbar flat back syndrome is made based on the patient’s history and x-rays of the spine. The patient typically has difficulty standing upright and may complain of back or leg pain. Previous surgical history is important, including the specific details of any past procedures. It is important to determine if the flat back syndrome is the result of a stable spinal structural abnormality or spinal instability. It is also important to determine if there is continued pressure on nerves where spinal stenosis is present.

Treatment for flat back posture:

Many patients with lumbar flat back syndrome may be treated without surgery. Initial treatment typically includes an appropriate physiotherapy-guided exercise routine to include aerobic fitness, weight-bearing exercise, and core muscle strengthening. The physiotherapist also uses spinal manipulation techniques that may also be beneficial depending on the patient’s symptoms.

Medications are commonly used to manage symptoms of lumbar flat back syndrome. For many patients, conditioning, and endurance programs may provide enough strength that symptoms improve. For patients with joint arthritis or pinched nerves, spinal injections can also provide relief.

Some patients with structural problems or severe curvatures may ultimately require surgical reconstruction. The goal of lumbar flat back syndrome surgery is to improve the patient’s pain and spinal alignment. The surgery goal is to restore a more normal alignment of the spine to decrease stress on supporting muscles of the back, hips, and legs.

Surgery may be an option if nonsurgical treatments do not relieve symptoms. Surgery may be needed for patients whose deformity is worsening over time, or who have curvatures leading to nerve compression causing symptoms such as numbness, weakness, or pain. Surgical reconstruction for flat back syndrome involves some correction of the curvature. The goals of surgery are to relieve pain and prevent the curvature from getting worse in the future.

Surgery to correct flat back deformity may be performed from multiple or combined approaches. The final recommendation is based on the desire to create the least invasive and safest procedure for each patient.

1. Flat thoracic spine
   a) Releases:

Thoracic paraspinals

Instructions:

Place your body weight on a massage ball in the areas to the sides of the spine and between your shoulder blades.
Find all of those tender areas!
Roll over the ball in a circular motion.
Spend at least 5 minutes doing the whole area.
Do NOT place the ball directly on the spine.

b) Stretches:

Stretch into flexion

Instructions:

Whilst sitting, interlock your fingers behind your neck.
Proceed to gently pull your neck downwards.
Focus on bending at the upper back as much as possible.
Aim to feel a stretch in your thoracic spine area.
Hold for 30 seconds.
Take deep breaths whilst in this position
Imagine the air expanding the area between your shoulder blades.

Stretch with a foam roller

Instructions:

Whilst sitting, place a foam roller on your lap.
Bend and round your back whilst your chest is in contact with the foam roller.
Focus on bending at the upper back as much as possible.
Aim to feel a stretch in your thoracic spine area.
Hold for 30 seconds.
Take deep breaths whilst in this position
Imagine the air expanding the area between your shoulder blades

c) Joint mobilization:

Rotations

Instructions:

Get into the 4 point kneel position.
Place one hand behind your head.
Proceed to twist your body to the side where the hand is on your head.
To isolate the thoracic region:
Do not allow your lumbar spine to move:
Brace your abdominals.
Keep your ribs cage low.
Repeat 20 times.
Repeat on the other side.

Translations

Instructions:

Whilst keeping your pelvis stationary, slide your upper torso to the side.
Try to also lift the shoulder on the side you are sliding to.
Aim to feel a stretch on that side of your torso.
Alternate both sides.
Repeat 15 times.
(This is a difficult one. Don’t worry if you can’t get it the first time!)

d) Improve Control

Standing intersegmental cat/cow

Instructions:

Whilst standing, wrap your arms around an exercise ball as much as you can.
Try to get your fingertips to touch.
Starting from the neck: Proceed to round your spine down one vertebra at a time until you reach mid-back.
Emphasize the rounding over the areas where your spine is the flattest.
From here, reverse your movements back to the beginning.
Repeat 20 times.

Intersegmental cat/cow

Instructions:

Get into the 4 point kneel position.
Hands in line with shoulder joint. Knees in line with hip joint.
Starting from the neck: Proceed to round your spine down one vertebra at a time until you reach mid-back.
Emphasise the rounding over the areas where your spine is the flattest.
From here, reverse your movements back to the beginning.
Repeat 20 times.

e) Regain your natural curve

It may take some practise… but you want to keep a slight natural curve in your upper back at all times.

If you don’t do this, your thoracic spine will likely just go back to being flat again.

1. Flat lumbar spine
   a) Releases

Hamstrings

Instructions:

Place your hamstrings on top of a massage ball.
Use your body weight to apply pressure onto your hamstrings.
Make sure to cover the whole hamstring muscle on both sides.

Abdominals

Instructions:

Lie on your stomach.
Place a massage ball under your abdominal region
Gently circulate your body weight on top of the ball.
Do not apply too much pressure.
NOTE: Do NOT squash your organs. STOP if it hurts.
Use deep breaths to help relax your muscles.
Spend at least 1-2 minutes.

b) Stretches

a) Upper hamstring

Instructions:

Whilst standing, place a slightly bent knee in front of you.
Lean forward by hinging at the hips.
Remember to keep your back straight!
Aim to feel a stretch in the upper portion of your hamstrings.
Hold for 60 seconds.
Alternate legs.

b) Lower hamstring

Instructions:

Whilst standing, place a straight knee in front of you.
Lean forward by hinging at the hips.
Remember to keep your back straight!
Aim to feel a stretch in the mid/lower portion of your hamstrings.
Hold for 60 seconds.
Alternate legs.

c) Abdominal

Instructions:

Lie on your stomach.
Place hands on the floor directly under the shoulders.
Straighten your elbows.
Arch backward.
(Note: Be careful if you have lower back issues)
Aim to feel a stretch across your abdominal region.
Breathe and expand your stomach as you stretch.
Hold for 60 seconds.

c) Strengthening

Sitting knee lifts

This is to activate the hip flexor muscles.

Instructions:

Sit up right.
Whilst keeping your back still, bring one knee up towards the roof.
Hold for 5 seconds.
Alternate on another side.
Repeat 30 times.

Superman

This is to activate the lower back muscles.

Instructions:

Lie on your stomach.
Stretch out your arms in front of you.
Lift your upper body and legs off the floor.
Hold for 5-10 seconds.
Repeat 30 times.

Pelvic tilt (4-point kneel)

Instructions:

Assume 4 point kneel position. (see above)
Tilt your pelvis forward.
Your back should start to arch
Hold for 10 seconds.
Repeat 30 times.

Pelvic tilt (In sitting)

Instructions:

Whilst sitting upright, proceed to tilt the pelvis forward.
Hold for 10 seconds.
Repeat 30 times.

Glute strengthening:

d) Maintain a neutral pelvis

If you do not maintain a neutral position of the pelvis throughout the day, then your posterior pelvic tilt will continue to be an issue.

Make sure that you tilt your pelvis forward to a neutral position whilst you are walking, standing, sitting, etc.

As your body has had this posture for a long time now, it will try to go back to it as a default setting. You need to resist this to prevent recurrent back pain and postural abnormality.

1. Other areas to consider

If you have a Flat back posture, then you will most likely have:

1. Forward head posture
2. Rounded shoulders

a) Forward head posture:

Sub-occipital release

Instructions:

Place the ball underneath the base of the skull.
Gently rotate your head on top of the ball.
Continue for 3-5 minutes.
Do both sides.

Chin tucks + nods

Instructions:

Gently tuck your chin in.
“Make a double chin”
Aim to feel a gentle lengthening sensation at the back of your neck.
Make sure to keep your eyes and jaw level. Move the head horizontally backwards.
Think of the movement as a book sliding back into the shelf.
Whilst maintaining this position, nod your chin downwards.
Hold for 5 seconds and repeat 30 times.

b) Rounded shoulders:

Chest stretch

Instructions:

Place both hands on the door frame.
Lunge forward.
Do not flare out your ribs.
You should feel a stretch in the front part of your shoulder/chest region.
Hold for 30 seconds.

Elbow flares

Instructions:

Start position: Place both hands (elbows forward) on the sides of your head.
End position: Pull your elbows all the way back.
Aim to feel your shoulder blade muscles contract.
Hold for 5 seconds.
Repeat 20 times.

Why do exercises for flat back syndrome?

The curve of your spine plays an important role in spine health, positioning your head over your feet, minimizing the effort of postural muscles, and allowing space between vertebrae for nerves. When you lose that curvature, those spaces can become smaller. Your body has to work harder throughout the day. And all of this can cause pain, tingling, or numbness.

Addressing the muscular deficiencies through exercise brings you closer to your natural lordosis (spine curvature), and helps prevent the pain associated with pressure on the nerves. Even though you may not have pain now, it’s wise to be proactive, as flat back syndrome can become a painful condition if left unchecked.

Flat Back Syndrome Exercises

The muscular deficiencies that patients with flat back syndrome suffer from include:

Tight hamstrings, pull the pelvis and rotate it abnormally. That condition, in turn, causes….
Weakening of the iliopsoas muscle (made up of the iliacus and psoas hip muscles), which aren’t being used normally when the back is flattened out.
Weakening of the abdominal muscles.

To correct these muscle imbalances, flat back syndrome physical therapy aims to accomplish three things:

1. Stretch and flex the hamstrings.
2. Strengthen the iliopsoas.
3. Strengthen the core.

The following exercises, done in combination, are a good approach to addressing flat back syndrome:

1. Stretch and flex the hamstrings.

There are lots of ways to do this, including:

Bend over from a standing position and touch the floor.
Use foam rollers to help loosen up the tightness in your hamstrings.
Try massage therapy, which helps to relax the hamstrings.

1. Strengthen the iliopsoas.

Sit in a chair and march in place, raising your knees toward your head by lifting your feet up off the floor. The primary muscle you’re using in this exercise is the iliopsoas.

1. Strengthen the core.

Try one or both of these exercises to strengthen your upper abdominal muscles:

The locust—Lay on your stomach on a mat, with your hands at your sides or on your lower back. Raise your head and shoulders off the mat. (This exercise helps you to stretch backward, counteracting the tightness of the upper abdominal muscle.)

The bird dog: Get down on your hands and knees, hips over knees, hands under shoulders, so you form a nice square. Raise your left leg and your right arm, balancing on the opposite hand and knee. Hold that position for a count of five. Then switch to the opposite side.

Ergonomics:

Sitting posture
Be sure the back is aligned against the back of the office chair. Avoid slouching or leaning forward, especially when tired from sitting in the office chair for long periods
For long-term sitting, such as in an office chair, be sure the chair is ergonomically designed to properly support the back and that it is a custom fit

When sitting on an office chair at a desk, arms should be flexed at a 75 to 90-degree angle at the elbows. If this is not the case, the office chair should be adjusted accordingly

Knees should be even with the hips, or slightly higher when sitting in the office chair
Keep both feet flat on the floor. If there’s a problem with feet reaching the floor comfortably, a footrest can be used along with the office chair
Sit in the office chair with shoulders straight
Don’t sit in one place for too long, even in ergonomic office chairs that have good back support. Get up and walk around and stretch as needed

Standing Posture

Stand with weight mostly on the balls of the feet, not with weight on the heels
Keep feet slightly apart, about shoulder-width
Let arms hang naturally down the sides of the body
Avoid locking the knees
Tuck the chin in a little to keep the head level
Be sure the head is square on top of the spine, not pushed out forward
Stand straight and tall, with shoulders upright
If standing for a long period of time, shift weight from one foot to the other, or rock from heels to toes.
Stand against a wall with shoulders and bottom touching the wall. In this position, the back of the head should also touch the wall – if it does not, the head is carried too far forward (anterior head carriage).

Walking Posture

Keep the head up and eyes looking straight ahead
Avoid pushing the head forward
Keep shoulders properly aligned with the rest of the body

Driving Posture

Sit with the back firmly against the seat for proper back support
The seat should be a proper distance from the pedals and steering wheel to avoid leaning forward or reaching
The headrest should support the middle of the head to keep it upright. Tilt the headrest forward if possible to make sure that the head-to-headrest distance is not more than four inches.

Posture and Ergonomics While Lifting and Carrying

Always bend at the knees, not the waist
Use the large leg and stomach muscles for lifting, not the lower back
If necessary, get a supportive belt to help maintain good posture while lifting
When carrying a heavy or large object, keep it close to the chest
If carrying something with one arm, switch arms frequently
When carrying a backpack or purse, keep it as light as possible, balance the weight on both sides as much as possible, or alternate from side to side
When carrying a backpack, avoid leaning forward or rounding the shoulders. If the weight feels like too much, consider using a rolling backpack with wheels.

Sleeping Posture with Mattresses and Pillows

A relatively firm mattress is generally best for proper back support, although individual preference is very important
Sleeping on the side or back is usually more comfortable for the back than sleeping on the stomach
Use a pillow to provide proper support and alignment for the head and shoulders
Consider putting a rolled-up towel under the neck and a pillow under the knees to better support the spine
If sleeping on the side, a relatively flat pillow placed between the legs will help keep the spine aligned and straight.

Conclusion

Loss of lower back curvature is the cause of flat back syndrome. It may occur as a result of a medical condition or surgery, or it may be present from birth.

Individuals with flat back syndrome bend their head and neck excessively forward. Pain and trouble balance may result from this.

X-ray imaging, a physical examination, and a medical history can all be used to identify flat back syndrome. Physical therapy and exercise are the usual forms of treatment, while surgery may be required in certain cases.

FAQ

Author: Nitesh Patel - Physiotherapist

Physiotherapist in Samarpan Physiotherapy Clinic Ahmedabad Bapunagar Amaraiwadi Vastral Mobile Physiotherapy Clinic Dr. Nitesh Patel ( Physiotherapist ) : Mo No : 09898607803