Sunday, December 1, 2013

Improving a Rounded Upper Back

It is fairly common to have or see others with a rounded upper back. The spine curves forward prominently, the shoulders collapse toward the chest, and the head protrudes in front of the torso. This includes the conditions known as "forward head posture" and kyphosis. These have been written about extensively, but I have a few things to add about mobility and strength training as treatment where the skeletal structure allows for change.

While deviations from some ideal posture have been long blamed for causing pain and dysfunction, these accusations are not necessarily supported by research. Rather than suggest that treatment will fix or prevent some health problem, I will simply assume that the reader wants a more upright and tall posture and proceed to offer suggestions to help with that goal.

I will mention one exception because of its importance to exercise. If the upper back and shoulders round forward, and the upper spine is insufficiently mobile, reaching overhead can potentially cause injury. Because the shoulder socket points more downward than it should, reaching overhead can compress the tissues around the front of the shoulder, or the low spine may arch backward to compensate for the upper spine position.

One final consideration well supported by research is that posture can affect a person's self-esteem, and the perception of others.



The approach I recommend combines stretching, strength building, and movement practice. The body must be both enabled to change and trained to enact the changes. The exercises shown follow a progression so the earlier ones are part of the later ones, and the same fundamentals of movement are used throughout. Please note that these are only a few of the many good stretches and exercises which may help, some others are referenced below.

Key Principles
1. The practice must become automatic and habitual, not just part of an exercise session.
2. Training more of the body at once is better than isolating individual parts.
3. Training must be sufficiently difficult to promote change, and progressively harder. Stress stimulates adaptation.

Anatomy Background
The areas of the body to address are the upper spine(the part of the spine from mid-back to the neck is the thoracic or "t" spine), the shoulder blades(scapulae), head, and arms. When the spine curves forward it is called flexion, and bending backwards is extension. The scapulae can slide toward the front of the body or together toward the spine, called protraction and retraction(they can also rotate and slide up and down). The head moving forward and back is a combination of neck extension and flexion. The rotation of the upper arm along its axis is the last component. This is actually referred to as shoulder rotation. Typically the shoulders have too much internal rotation, bringing the forearms across the torso.

It is important to remember how connected these parts are. Each scapula has muscles attaching it to the spine, and the head of the arm sits against the scapula in what's known as the rotator cuff. Train the spine, scapulae, and arm together because that is how they are used normally. Isolating one part may be necessary in physical therapy, but not in functional training.

Incorporate your breath in all of these exercises. Use deep inhales on stretches to actively expand and lengthen, and on exhales relax further into position. On exercises requiring strength, on the inhalation focus your energy, then use the exhalation to aid in producing force.

One more point is don't try to create the t-spine extension by hyper-extending(arching) the low or lumbar spine. Hold your abdominal area tight to prevent this, also check the position of the bottom of the rib cage. The rib cage should not tilt or flare up and pull away from the pelvis.

Typical slumped posture
Anatomically better posture

On the left is t-spine flexion, scapular protraction, and internal rotation of the shoulder. This is not a good position to hold. On the right is much better default posture. Please note that movement and variation are more important than holding a single position rigidly. The exercises below aid in achieving and holding the posture to the right.
(Fortunately I am not very good at showing how bad kyphosis can be, but I decided not to include any scary illustrations of the worst cases.)




Mobilizations

Shoulder Twist in Quadruped 
'Cat' plus easy shoulder twist down
'Cow' plus shoulder twist up
Begin in quadruped(hands and knees) to start moving the t-spine and shoulder from a constrained position. If you are familiar with cat/cow from yoga the spine part of this exercise will be familiar, with the addition of t-spine rotation and shoulder retraction and protraction. Go from a gentle 'cat' with flexed spine and protracted shoulder up to a strong 'cow' working hard to extend and twist the t-spine and pull the scapula up and in. Be sure the shoulder doesn't elevate toward the ear, and keep the hips in position- don't let the twist happen there.

Shoulder Sweep
Start - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -> Finish
Start by reaching forward
Sweep the arm along the ground above the head, tracking the hand with the eyes. The lower leg is straight, and the upper leg is bent, with the knee pressing on a medicine ball, foam roller, yoga block, etc, to keep the pelvis from turning. Start by reaching forward and allowing the back to round as I show in the close-up, then straighten the spine and pull the shoulder back as the hand sweeps along or near the ground. Engaging your vision really helps achieve a better range of motion, and keep extending the t-spine the entire time.

Shoulder Traction
Here's a stretch that adds joint distraction in the shoulder. This is a good place to practice using your breath to enhance the stretch. Move the body to stretch at different parts of the joint, and don't neglect to extend the upper spine, as shown in the third panel. Add shoulder external rotation- in this position the thumb points backwards.

Shoulder traction

To the left is a way to do the stretch with a dowel or broomstick. In this version the lower hand pushes up and back on the arm being stretched, and turns it into external rotation. The stick and pushing arm can also be held behind the torso.









Stick Overhead Reach
Next is another way to use a stick for mobilization. Working both shoulders at the same time makes it possible to really emphasize scapular retraction. Another way to think about the movement to try to push the chest through the shoulders. Include external rotation in the shoulder by trying to bend the stick, with the middle bowing forward(most sticks won't actually bend, you just make the effort in order to activate the muscles.) Do the exercise for reps, bringing the bar up from hip level to over and behind your head, holding for a second or two. Try to arrive in the stretched position when the stick gets to the top. Twist the body vertically, and raise one arm higher on each side as you turn(my photo doesn't show this well). There should be a diagonal stretch from one foot across the front of the body to the opposite hand.

Shoulders together
Chest open
This starts as a mobility drill, but can be progressed by adding a resistance challenge. Many gyms have weighted bars used for aerobics classes that work very well for this. Twelve pounds is a common weight, and that's plenty for most people. The combination of mobilization and strength building makes this a programming staple for many of my clients.



Exercises

Typically when we choose exercises, we think of muscles or areas to strengthen, and that is the basis for the first two exercises shown. The facepull and row directly target the muscles in the back of the shoulders and the t-spine. In functional training, we think of movements to train and for posture, I suggest thinking in terms of global movement patterns. Do some specific corrective exercises, but of equal importance is to make every exercise in your workout part of your posture program. What that means is creating the habits and the 'motor patterns' to maintain posture in a wide variety of situations, not just the ones deliberately focused on the areas of interest.

(Motor patterns are how all the muscles contract and relax to to conduct a physical activity. For instance, to lift a weight overhead some shoulder muscles create the force to move the weight up, others hold the arm securely in the shoulder socket, and muscles in the spine and hips are very active in giving a stable base for the shoulder.)

As you do any exercise, make the elements of movement described above part of the motor patterns you are teaching yourself. Some examples:

Facepull
Cable machine with rope handle                                                                            Elastic bands
This exercise is primarily for the back of the shoulder to counteract the typical position of having the arms internally rotated and held in front of the body, such as at a computer. The t-spine can still be included, and it is surprisingly hard to keep the head held back. Beginning and end positions are shown on an adjustable cable machine with a rope handle, then a way to do a facepull with only elastic bands is shown on the right. This could be done with a single long band and a hand towel substituted for the red band shown. Create all the movement with the scapulae and arms, and don't lean or arch back. Very little weight or resistance is needed, as this is not a strong position for the shoulder. Five to ten pounds will be enough for most people.

Bent Over Row

First shown with kettlebells, then resistance bands. The weights or band try to pull you into a rounded position, you do the opposite. It takes practice to hold alignment here, so this is a good place to check yourself with a camera.




Hold a kettlebell or dumbell in each hand. Fold forward at the hips, not the waist, keeping the entire back straight. Pull the elbows up while retracting the shoulders. Try to extend the t-spine even more at the top, and keep the head in line with the spine and pulling backward. Don't let the shoulders move toward the ears, actively pull them toward the hips. This is sometimes called "putting your shoulders in your back pockets." With resistance bands the positioning of the body is the same.

Farmers Walk
Shoulders back!
Tall, head back!
An all-round excellent functional exercise, great for building strength and endurance, it also provides a way to train posture in a normal upright position with the challenge of carrying heavy weights. The procedure is simple -pick up the weights, assume your long spine, head and shoulders back and arms slightly turned out- alignment, and walk. In the variation shown the weights are of different sizes to train the spine to to resist lateral flexion(bending sideways.)  Both weights can be the same, and if you try an offset load a lighter one half to two thirds the weight of the heavier one works well. Walk anywhere from 10 to 100 meters, switching the weights half way if they are unequal. Recheck that you have good alignment as you go- since walking is such a simple and familiar activity you can easily do this and make adjustments.

Other Exercises
One of the best exercises for building strength is the deadlift, and it can be very helpful for the upper back and shoulders if done correctly. However it is difficult to learn and easy unknowingly to do poorly, so get professional instruction before adding it to your workout. If you have pronounced kyphosis I wouldn't do it at all. Likewise kettlebell swings are good at working the same muscles and are easier to learn than the deadlift, but keeping good upper back alignment takes coaching and practice. The Crossfit, or American, swing, is very risky for the shoulders of anyone with a rounded upper back- do Russian style swings only.

The superman exercise, prone "T," and from yoga, cobra posture, can be helpful. Wall slides and forearms slides are also good. I don't discuss these and some other common exercises for t-spine mobility because they can't be progressed with more resistance, or they are not done in a functional, upright position. They aren't a bad start though.

Avoid crunches and situps. These train the body to move into exactly the alignment that you are trying to avoid. Bench presses and other chest exercises are also problematic- over-active and shortened chest muscles may be present already and you don't want to activate them even more. Another one I have seen pictures of is the use of heavy chains draped around the neck to work the upper spine extensors. Mechanically it makes sense, but even the instructors demonstrating it seemed unable to hold good form, so I don't recommend this method.

Conclusion
Forward head posture and kyphosis are not reason for alarm or necessarily a source of pain or dysfunction, but it may still be beneficial to decrease them. If choosing to address these conditions, a combined approach of increasing flexibility, strength, and movement training is suggested. Ultimately what will make the most difference is learning to incorporate the changes practiced in your training into your sitting, standing, and moving without conscious effort.


Thanks to Angie and Mimm(website) for their assistance. Photos were taken in Hoover and Heritage Parks in Palo Alto.

Further Reading and Viewing
(Caveat lector!)

Posture
Body Posture Affects Confidence In Your Own Thoughts, Study Finds
Standing Tall Is Key for Success: 'Powerful Postures' May Trump Title and Rank
Your Mother Was Right: Good Posture Makes You Tougher
Five Misconceptions About Posture
Three Essential Elements of Good Posture

Spine and Shoulder Mobility
Simple Thoracic Spine Mobility Exercises Everyone Can Perform
Improving Thoracic Mobility in Throwers