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  • 1. The Prevention of Posture–Related Problems in Orthodontists, Their Staff, and Their Patients. John Christman, Ph.D. www.powerposture.com III Barcelona Orthodontic Meeting 13-15 March 2003
  • 2. Lecture points:
    • The general problem of poor posture, the biophysical problems it causes, how those problems are magnified in dental practitioners, and how to reduce or eliminate them.
    • The effects of poor posture on jaw development and jaw function (including temporomandibular disorders), and what an orthodontist can do to motivate patients to improve his/her posture.
    • Posture-related dental research in progress or planned at the University of Tennessee, and suggestions for future clinical research.
  • 3. Introduction
    • The head-neck support system can be likened to a 4-5 kg. ball on a flexible shaft stabilized by guy wires. The muscles pull down to stabilize, so the stronger the muscles, the more force is transmitted through the spinal column. Therefore, the least stress on the spine will occur when the head is basically centered over the spinal column below, so that minimum muscle tension is necessary to hold the head up. This optimal biomechanical position is achieved with what is accepted as normal, good posture.
  • 4. Proper, Optimally Efficient Posture
    • Proper posture occurs when:
    • The shoulders are held back and down
    • Thoracic spine curves forward only slightly
    • Scapulae are flat, do not "wing out”
    • The chest curves out - forward tips of the shoulders would not touch a yardstick placed across the upper chest
    • The collar bones are level or slope only slightly upwards
    • From the front, the chin is at least 5 cm, if not 8 or 10 cm, above the clavicular notch.
  • 5. Proper, Optimally Efficient Upper Body Flexibility
    • Rotate arms forward and upward to vertical, without leaning back.
    • Rotate head left and right 90°, without tilting head back.
    • Sit and reach to mid-calf.
    • Press elbows inward behind back, often touching.
    • Arm overhead, pull elbow behind head without ducking.
    • Throw with full shoulder range of motion.
  • 6. Proper, Optimally Efficient Posture
    • Line of gravity: Earlobe over the middle of the shoulders, over the hip joint, and over a point about 2 cm in front of the ankle joint.
  • 7.
    • Every 2-3 cm forward the head is held forward of this position requires the exertion of 7 to 14 kg of extra muscle tension, which means that that much less muscle strength is available to support outside loads. This extra muscular load is transmitted down the spine, increasing chronic loading on the vertebrae as well as the intervertebral discs.
  • 8. Saunders Manual of Physical Therapy Practice:
    • "Poor posture" is a faulty relationship of the various parts of the body which produces increased strain on the supporting structures and in which there is less efficient balance of the body over its base of support. When resting posture is not "normal", more energy is needed to perform or control movements; e.g., forward head posture puts increased stress on the cervicothoracic spine and requires more work from the erector spinae muscles to maintain an erect posture. (Recall the 7-14 kg of extra work necessary for each inch of forward head displacement.)
  • 9. Forward Head Posture
    • Forward head posture involves flexion of the lower cervical spine in combination with extension of the upper cervical spine. It is often accompanied by protracted scapulae and increased thoracic kyphosis.
    • In the general population, the incidence of forward head posture is very high. One study of 88 healthy subjects, ages 20-50, found forward head posture in 66%, kyphosis in 38%, right rounded shoulder in 73%, and left rounded shoulder in 66%.
  • 10. Johnnie Watson Memphis City Schools Superintendent
  • 11. Forward Head Posture and Back Safety
    • Misalignment in the upper back, neck, and head results in a compensatory, dysfunctional adjustment in the lower back to maintain balance over the hips.
    • The excess backward curvature from the upper back kyphosis typically results in excess lordosis, or forward curvature, in the lower back, increasing chronic strain and decreasing overload tolerance in that area.
  • 12. Effects of Poor Posture on Muscles and Spine
    • Muscles habitually kept in a stretched position beyond the physiologic resting position tend to weaken. This is known as stretch weakness.
    • Muscles habitually kept in a shortened position tend to lose their elasticity. These muscles test strong in the shortened position but become weak as they are lengthened. This is known as tight weakness.
  • 13. Forward Head Posture: Effects on Muscles
    • Joints Affected Short Muscles Weak Muscles _______________________________________________________________________
    • Atlanto-occipital Levator scapulae Hyoid Cervical spine Sternocleidomastoid Lower cervical and thoracic erector spinae Temporomandibular Scalenes Middle and low  trapezius Scapulothoracic Suboccipital Rhomboids Glenohumeral Upper Trapezius Pectoralis major Pectoralis minor
  • 14. Kyphotic Posture: Effects on Muscles
    • Joints Affected Short Muscles Weak Muscles _______________________________________________________________________
    • Thoracic spine Intercostales Levator scapulae   Pectoralis major Upper trapezius   Serratus anterior Thoracic erector spinae Rhomboids   Middle and lower trapezius
  • 15. Effects of Poor Posture on Muscles and Spine
    • Imbalances in the flexibility of hip, shoulder, and neck musculature causes asymmetric forces on the spine (which decrease load bearing capability and increase injury risk).
    • Kisner and Colby, in Therapeutic Exercise , 3rd edition, state that this adaptive shortening of soft tissues and muscle weakness, caused by prolonged poor postural habits is considered to be a postural dysfunction. Stress to the shortened structures causes pain, and strength and flexibility imbalances may predispose the area to injury or overuse syndromes that a normal musculoskeletal system could sustain. Good postural habits are necessary to avoid postural dysfunctions.
  • 16. 50 Years Later
  • 17. “Aged” Posture
    • Head forward – from years of forward reaching and leaning
    • Shoulders rolled forward – from years of forward reaching and leaning
    • Sunken chest – because of loss of abdominal support (“bottom has dropped out”) and tightened chest muscles
    • Protruding abdomen – from loss of abdominal muscle tone
    • Thicker waist – from sunken chest pushing viscera outwards
  • 18. Functional Effects Of “Aged” Posture
    • Earlier fatigue resulting from Increased postural muscle loading due to:
      • More body mass farther from midline.
      • Less efficient muscle angles and muscle lengths.
    • Increased spine loading while bone density is (probably) decreasing means greater fracture risk.
    • Decreased cardiopulmonary system efficiency – decreased lung inflation, especially at apex (possible pneumonia risk?).
    • Decreased muscle efficiency, strength, and flexibility reduces performance capacity in all physical activities and sports (reverse example: world class age-group athletes usually have great posture.)
  • 19. The Relationship Between Posture And Pain Or Fatigue Is Variable Between People
    • Some with near-perfect posture can have great pain, while others with very poor posture can have little or no pain at all.
    • The stronger and more fit the person, the more likely their muscles can tolerate poor posture without pain. But spinal loading from the poor posture is still large, so to prevent long-term degenerative problems, postural improvement is still called for.
    • Empirically, women seem to have more pain and fatigue problems than men. Makes sense from a power to weight perspective- women generally have less strength per kg body weight.
  • 20. Research Evidence That Worse Posture Is An Inevitable Part Of Normal Aging…
    • NONE!
    • Most people could be as straight at age 80 as at age 20 if they could maintain their normal muscle flexibilities and strength balances.
    • Height loss of more than 2 – 3 cm is due more to posture than intervertral disc compression (20 mm / 23 discs ~ 0.9 mm/disc; 3-10 mm thick discs ~ 7 mm avg.; 0.9 mm/7.0mm ~ 13% avg. loss)
  • 21. Upper Body Problems In Dental Practice: A Serious Issue
    • Serious neck, shoulder, and upper back pain, fatigue, and injury problems, as well as posture so poor that it affects general physical performance, are disturbingly common throughout the dental profession. Forced early retirement due to neck, shoulder, and back problems is a frequent occurrence in dentistry.
  • 22.
    • All the years of training, skill acquisition, and capital investment are worth nothing if you can't hold up to the physical demands of dental practice and then retire healthfully. A dentist friend of mine's chiropractor told him that "100% of dentists have or will have these problems." This may be a facetious exaggeration, but not by much!
  • 23. Dr. Gerry Campbell University of Tennessee Dept. of Dentistry:
    • “It is generally recognized that dentists and their staff suffer from musculoskeletal disorders affecting their upper thoracic and cervical spine and its musculature. Many epidemiological studies have identified these as pain and discomfort in the neck and shoulders; headaches; low back pain; occupational burnout; and peripheral neuropathy in the upper limbs and neck. Although there are many studies identifying these conditions, there are very few sources of information on how to do proper stretching and strengthening exercises to help the busy dentist and staff to overcome these problems.”
  • 24.
    • Sit down dentistry has greatly reduced the neck, shoulder, and back strain in dental practice, but the strain cannot be totally eliminated. The dental practitioner must increase his/her ability to tolerate the strain. But how?
  • 25. Connection of Physical Stresses of Dental Practice To Posture
    • The unavoidable postural and positional stresses of dental patient treatment mimic the biophysical stresses of forward head, round-shouldered posture.
    • If you have poor posture, you magnify the effects of those physical stresses on you.
    • And if you allow your posture to get worse with age, that further weakens your neck, shoulders, and back, making it more difficult to hold proper posture, leading to further postural worsening, and so on in a vicious cycle.
  • 26.
    • Besides helping to reduce lower back problems, proper neck, shoulder, and upper back posture and flexibility will decrease or eliminate the typical pain and fatigue which so many people interpret as "job stress", but which is really biomechanical overload from improper posture. Professions which have a high incidence of neck and back problems, like dentistry and surgery, will especially benefit. And in desk jobs, the neck, shoulders, and upper back will be no more fatigued at the end of the day than the rest of the body with proper posture and flexibility.
  • 27.
    • To maximize your ability to tolerate the physical stresses of dentistry, optimal spinal biomechanics, muscle support, and muscle flexibility should be developed and maintained.
    • The specific goals of such a program should be to:
    • Position the head and shoulders for best biomechanical support.
    • Strengthen the muscles necessary to support the head and shoulders.
    • Stretch out the chest and anterior shoulder muscles against which the back and posterior shoulder muscles have to work when holding the head and shoulders up.
  • 28. “Just stand straight”?
    • Chronic slouching posture causes muscle flexibility losses and strength changes which maintain that posture and make it virtually impossible to improve posture by “just thinking about it” or “just doing it”.
  • 29. Forward Head Posture Cure
    • Practicing "straightening up" may slowly cure forward head posture, but it will not totally reverse the loss of flexibility associated with such posture.
    • Active exercise intervention, to specifically correct the strength and flexibility deficits associated with forward head posture, is necessary for a time-effective, assured cure.
  • 30. Training Methods For Maintaining Normal Upper Body Flexibility And Posture
    • Daily stretching and strengthening exercises specifically designed to maintain proper posture and flexibility. Takes 10 – 30 min/day, depending upon profession and lifestyle habits. Can make postural correction a subconscious response, reducing corrective needs.
    • Weight training designed with postural considerations.
    • General stretching programs like yoga, Alexander Technique, Pilates. (Cost and time factors; do not focus on upper torso enough to cure forward head posture or cure pain and fatigue in all cases)
  • 31. How Effective Can Postural Improvement Be In Relieving Pain And Fatigue?
    • Posture improvement via increased flexibility and strength has relieved back, neck, and/or shoulder pain in cases where X-rays and MRI found nothing structurally wrong, and practitioners in general medicine, neurosurgery, orthopedics, chiropractic, physical therapy, and/or massage therapy were unable to provide any permanent relief.
  • 32. A stretching and strengthening program which will reestablish normal upper body muscle flexibilities and muscle strength balances is the following:
    • Elbow lift behind the back Stretches
    • Stomach crunches Strengthen
    • Side of chest and outer back stretch Stretches
    • Neck stretching Stretches
    • Chin glides Stretch and strengthen
    • Shoulder rolls Stretch and strengthen
    • Elbow press behind the back Stretches
    • Standing stomach strengthener Strengthens
    • Back flattening Stretches and strengthens
    • Sit and reach Stretches
    • Upper spine straightener Stretches and strengthens
    • Air rowing Stretches and strengthens
  • 33. Stretching and strengthening program, continued:
    • Doing exercises 1-6 and 7-12 on alternate days, this program:
    • Takes 10 min/day on average,
    • Anyone of any fitness level can do it.
    • Can be done virtually anywhere with no additional equipment.
    • Will relieve acute pain in the office.
    • Will prevent, reduce, or cure neck, shoulder, and back pain and fatigue.
    • Should reduce the risk of permanent spine and shoulder injuries.
    • Can increase height, flatten stomach, reduce waist, increase fatigue resistance, and improve performance in virtually all physical activities and sports.
    • Is available on video - The PowerPosture Program
  • 34. Power Posture Contents
    • Starting Time Section Title 0:00 Title and Introduction     3:27 Posture/Pain/Performance    12:50 Self-assessment 23:37 Exercise program    44:07 Lifestyle Suggestions    50:21 Perspective and Summary. 52:44 Weight Training 62:00 End of Program
  • 35. Dr. Gerry Campbell University of Tennessee Dept. of Dentistry:
    • “Now, there is an easy-to-follow, gentle, and comprehensive program on videotape that meets these needs – PowerPosture . The 10 to 15 minutes daily to do this program could allow it to be done during regular office hours. This program can increase your productivity while improving your sense of well-being.”
  • 36. Potential uses of Power Posture in dentistry:
    • All dental office staff – anyone who has neck, shoulder, and/or back pain and fatigue, or wants to preserve or improve their posture.
    • Child or adult patients who need to improve posture for optimal dental development and health.
    • Dental students and dental hygiene students, to prevent onset of problems.
  • 37.
    • The PowerPosture stretching exercises reestablish normal muscle flexibility and muscle strength balances, producing “automatic” straight posture.
    • But more importantly for dental practitioners, no matter how good or bad your posture is, these exercises will reduce the effects of the physical stresses of dentistry on you, and increase your physical ability to tolerate them.
    • And better posture will benefit your image with patients and the general public.
  • 38. Posture Studies Excerpts
    • Research studies going back at least to 1985 have firmly established a link between forward head posture and dental disorders. Study excerpts include:
    • Forward head posture can influence craniofacial growth, and can lead to a morphoskeletal and neuromuscular pattern leading to a dysfunctional condition. Craniocervical postural position is closely related to the mandibular postural position.
    • A correlation exists between forward head posture, craniomandibular dysfunction, and class II occlusion.
    • Many musical instruments cause TMD because of the effect of the playing position on the head and neck structures.
    • When evaluating the ear position with respect to the seventh cervical vertebra, the head was positioned more forward in the group with TMDs than in the control group.
  • 39. Study excerpts, continued:
    • Forward head position had a significant relationship to TM disorders in children with mixed dentition.
    • The significance of the relationship between the rest position of the mandible and forward head posture has been shown by the changes observed after correction of the postural deviations and vertical resting dimensions by dental treatments and physical therapy.
    • Over 50 million Americans, mostly women, currently (1992) operate video display (VDT) terminals at home or in the workplace. More than 79% of approximately 30 million American TMD sufferers are women. VDT operation may be linked to postural stress associated with poor work habits and improper work station design. Dentists are advised to educate patients as to these possible risks, encourage preventative behaviors on the part of employees and employers, and recommend workplace health, safety, and ergonomic upgrades when indicated.
  • 40. Study excerpts, continued:
    • A forward head position and rounded shoulders have been implicated in the development or perpetuation of craniomandibular disorders. Symptomatic women displayed these postural characteristics to a greater extent than asymptomatic women. Evaluation and treatment of postural dysfunction should be included in the management of these patients.
    • The head neck, and upper thorax of five naive patients demonstrated increasingly anterior and inferior displacement during five minutes of relaxed sitting. Sitting posture must be assessed in relationship to the patients’ length of time sitting, awareness of being observed, level of instruction on how to sit, and chair style.
    • Craniocervical dysfunction scores were higher in patients with TMDs than in control subjects. These patients should be screened routinely for craniocervical problems.
  • 41. Dr. Gerry Campbell University of Tennessee Dept. of Dentistry:
    • “Numerous national and international studies have identified forward head, round-shouldered posture as a temporomandibular disorders (TMD) cofactor. It is recognized that cervical and upper thoracic examination (range of motion, tenderness on palpation, pain referral, etc.) should be part of a thorough TMD examination. It is also recognized that if positive findings are revealed, they should be addressed as part of a multidisciplinary treatment plan. These usually include stretching, strengthening, and relearning postural habits.”
  • 42. Dr. Gerry Campbell University of Tennessee Dept. of Dentistry:
    • “The PowerPosture program addresses all 3 of these factors in a concise, easy-to-understand and gentle approach which can cure forward head posture, and reestablish proper upper body posture, flexibility and range of motion. Thus the TMD practitioner can now prescribe an inexpensive, thorough, and easy-to-learn videotape to help his or her patients. General practitioners can also prescribe this tape for those patients who exhibit forward head posture and who are thus at risk for developing TMD.”
  • 43. Orthodontia– Related Reasons For Your Patients To Improve Their Flexibility And Posture
    • Tell parents and patients: “You are spending several years and a lot of money to have an attractive smile and proper tooth alignment. One thing you can work on on your own to help your jaw develop properly and to help it work properly is your posture! Ten minutes of daily stretching is all you need to do. And by doing this, you will not only get better results from your orthodontia, you will have many other benefits, which include:”
  • 44. Nondental Reasons For Orthodontic Patients To Improve Their Flexibility And Posture
    • Improved function of the entire body, including internal organs.
    • Clearer thinking and better productivity due to less pain and fatigue.
    • In students, reduced likelihood that heavy school back packs, extensive time using computers and/or videogames, and long study hours will cause poor posture and long-term back problems.
    • Have the posture and upper body flexibility required for peak performance in most sports.
    • Have the posture required for the flattest stomach and smallest waist possible – space to “suck in gut”; straight line muscle pull.
    • Prevent height loss with age, or regain height lost to poor posture.
    • Better driving safety because head mobility is better with an upright head position and more flexible neck and shoulders.
  • 45. Posture-related research in progress or being planned at the University of Tennessee
    • Reduction of TMD symptoms and incidence with improved upper body posture, flexibility, and strength.
    • Reduction of head and neck pain with improved upper body posture, flexibility, and strength.
    • Effects of improved posture and head position in jaw development in children.
    • Effects of improved upper body posture, flexibility, and strength on pulmonary function and exercise capacity in normal children and adults, and in patients with chronic obstructive pulmonary disease.
  • 46. Summary:
    • Daily, targeted stretching to improve or maintain proper upper body flexibility, strength, and posture will enable dental practitioners and their entire office staff to cope with the unavoidable postural and positional stresses of dental practice and office administration.
    • If substandard posture is found in orthodontic patients, for the best orthodontic results they should be given a postural training program.
  • 47. The Prevention of Posture–Related Problems in Orthodontists, Their Staff, and Their Patients. John Christman, Ph.D. www.powerposture.com III Barcelona Orthodontic Meeting 13-15 March 2003
  • 48. www.powerposture.com/barcelona Download this presentation in Microsoft Powerpoint, Apple Quicktime, or Adobe PDF format here: