If you have spent any time at all in the massage world you will probably have heard of postural assessment. Like many of us, you have probably got more than your fare share of clients suffering from upper back and neck pain, perhaps resulting from the fact that they spend long hours slumped at a desk in front of a computer monitor with terrible posture. And like all good massage therapists you were probably taught to take a detailed case history before beginning treatment with each new client, asking about old injuries and ailments, as well as about current medical conditions, medication and possible contraindications. Once you have completed your case history, then what do you do? You probably help your client straight to the couch ready to receive treatment, and that is that.
But what if you were to do a brief postural assessment? That would be an excellent way to start because it would help you establish a baseline-a marker by which you might judge your effectiveness. If your client has muscular pain resulting from poor posture, wouldn't it be a good thing to have a look at their posture and make a note of it? Perhaps you could even record their posture over time and record any changes? Of course, not all clients would feel comfortable standing in their underwear having their posture assessed prior to their first treatment! But perhaps we all ought to be encouraging postural assessment as part of our initial consultation. You client has, after all, probably just revealed some intimate details about their state of health and if they are coming to you as the result of posture-induced pain, it seems reasonable to encourage them to let you spend just a few minutes doing what will add to your overall assessment, and what may enhance your treatment.
So, here is the beginner's guide to postural assessment! For this article let's concentrate on carrying out your observation of sitting posture. You do not need to set up an office-type environment-there are so many variations in chair and table heights. All you need is an upright chair.
1) You are going to ask your client if you can observe them as they pretend to sit at their desk. How are you going to ask them to do this? If you say "I'd like to observe your posture in sitting" do you think they are likely to sit with their usual posture or with a false-perhaps better-posture? Probably, they'll hear the word "posture" and straighten up and sit with a really straight back when what you want them to do is to assume their daily position which is likely to be more of a slouch! So, perhaps start by saying, "I'd like to observe how you sit if that's ok", omitting the word "posture" altogether.
2) Think about how you are going to justify this. What will you say when they ask "Why. What's it for?" You could day things like, "It will help me get a feel for the position your muscles are in whilst you work," or, "it helps us assess the relationship between muscles to see which might be strong and which might be weak". The relationships between some body parts are very obvious when a client is sitting but are less obvious when they lie down. For example, in siting it is easy to see whether a client has (protracted) "round shoulders" whereas lying in prone (face down) the shoulders fall into a different position than that which they maintain during the day. Overall you need to get across the fact that assessing a sitting posture will help you to gain more information about the clients body and will thus allow you to tailor your treatment more specifically to them. You could even explain that massage often involves gentle stretching soft tissues so if we are clear about which soft tissues to stretch we can be more effective. Many clients like this approach because it demonstrates caring and a high level of professionalism.
3) Ask your client to assume the position they think they are in at work, imagining they are typing or using a computer mouse. Ask them to demonstrate how they sit for the majority of the day, not just the good position they take up when they first come into the office at 9.30am! Stand to one side of them and make an immediate mental note of what they do and ask yourself the following questions:
a) Is their desk directly in front of them or to one side? If the desk at which they work is positioned even just a little bit off centre they will have increased spinal rotation to that side. So already you have learned something useful. (Tip: look up the muscle called quadratus lumborum and make a note to compare both sides. What do you notice about this muscle on the side to which the client rotates?). Neck rotators will also be unequally tight.
b) Does your client appear to have a kyphotic posture, that is, does their spine appear to curve outward. Usually, as the day progresses our posture worsens as we assume that position that requires the least amount of effort to sustain. The outward curvature of the back becomes exaggerated and we slump down. There are many consequences, including shallow breathing due to a compressed rib cage, internally rotated shoulders, tightened pectoral muscles and a lordotic neck.
c) Observe your client's neck. Can you even see their neck! Try this yourself. Imagine you are sitting at a desk and looking at a computer screen. Gradually crumple yourself down to become more and more slumped. What happens to your neck? It goes into increased lordosis, contracting the upper fibers of trapezius, levator scapulae and upper rhomboids.
d) Does your client use a telephone a lot at work? If so, ask them to demonstrate: do they use a headset or wedge the telephone under one ear, increasing tension in neck extensors on that side?
e) Gently palpate the medial border of each scapula. That is, the edge of the scapula closest to the spine. Are these borders equidistant? In slumped postures they are likely to be protracted and positioned too far away from the spine. This results in lengthened and weak rhomboid muscles.
f) Unless your client has a very good working posture it is almost inevitable that they will have medially (internally) rotated arms. In which case muscles such as pectoralis major, anterior deltoid and teres major will be shortened and tight. The humerus may assume an anterior position in its socket and together this can lead to anterior shoulder pain.
g) Look at the client's pelvis. By the end of the day it has usually gone into what is called posterior tilt, flattening the lumbar curve. In the sitting position, hip flexors (such as psoas and iliacus) are in a shortened position and can aggravate lumbar pain due to the origination of psoas on the lumbar vertebrae on which it exerts force.
h) Sitting puts hamstrings in a shortened position and, if the client is wearing high heels, the feet are in plantar flexion which may result in tight calf muscles.
Can you see how carrying out a simple assessment of sitting posture may help explain why your client has stiffness and/or pain? Practice on family and friends and you will soon see that this form of assessment is both easy and useful.
If you'd like to ask any questions about this article, please be in touch.
By Jane Johnson Chartered Physio Therapist MCSP, MSc, BSc, BA (Hons)
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