Your mom told you to sit and stand up straight and you didn’t listen. You were too cool for that. Slouching snubbed the strictures of puritanical rigidity. Slouching was more down to earth, more human, more humble.  You left the confines of your childhood and your mother’s world of rules, manners, and straight backed chairs.

Years passed. When you saw your own kids double over their devices, you repressed your repugnance, dismissing it as an artifact of your own upbringing.

Then you noticed your mom, once an obelisk, started stooped over a little.  Then she fell and had a vertebral fracture and the pace of stooping quickened. She coughed more. She got sick more frequently. She walked slower. She fell again, and again.  She became ornery, depressed, listless. It was as if she had bent over and poured out all her former vigor. Each visit brought you face to face with her decline. You found yourself telling her to stand up straight. You began to feel self conscious about your own posture. And then you wondered…

Was mom right about posture? Are there negative health effects of poor posture? Was her hunched posture inevitable or was it a banner of her resignation? Does bad posture cause weakness, disease and dysfunction or is it a symptom of those things? Was her bent over frame part of the reason she fell so often? Was her inability to sit up straight, to take a deep breath, to swallow easily or cough fully part of the reason she kept getting pneumonia? Can bad posture be fixed, or is it inevitable? Is it genetic? Is there anything I can do to prevent myself from being hunched over in old age? Does posture even matter?

It is easy to find articles and advice from a cornucopia of health care providers preaching the importance of posture and exhorting you to improve it. But these sources often lack a rigorous and unbiased investigation of the research literature regarding the functional correlates and consequences of poor posture. This is what I attempt to provide below.

What is bad posture?

The key component of the hunched over posture I am referring to is “thoracic hyperkyphosis.” Thoracic hyperkyphosis is an excessive forward bending of the upper back (the thoracic spine) [1]. It is often accompanied by “forward head posture” and variably accompanied by a lower back posture of excessive (hyperlordosis) or diminished arching (flat back). Our young chimpanzee friend above is demonstrating a combination of forward head posture, thoracic hyperkyphosis, and flat back (normal posture for pan troglodytes). Our main focus here is on thoracic hyperkyphosis as this posture has been the most well researched and is most clearly related to ageing, morbidity and mortality [1].

Posture and risk of death

Is your bad posture a sign of impending doom? Our first clue comes from the prospective cohort Study of Osteoporotic Fractures. Thoracic kyphosis posture was measured in 606 women over the age of 65. At an average follow up of 8.3 years later, there were 2.6x more deaths from lung dysfunction in those who were the most hunched over (the top 20% of thoracic hyphosis) when compared to the most upright (bottom 20% of thoracic kyphosis) [2].

Our second clue comes from the 1,353 men and women of the Rancho Bernardo Study in California [3]. While lying on their back on the radiology table for their x-ray, participants were asked to rest their head on the table without extending their neck. If one or more 1.7cm blocks had to be placed behind their head in order to achieve a neutral spinal position, they were classified as hyperkyphotic. (you can lie down right now and test yourself). Over the next four years, the rate of death in this bent-over group was 1.44x greater than the others in the study and this hyperkyphotic posture was specifically associated with death from heart disease (atherosclerosis) [3].

These are robust findings and the prospective nature of these studies allows us to say confidently that a stooped posture predicts an increased risk of death. But were these deaths caused by complications of poor posture itself or is poor posture merely an early symptom of an underlying decline in physical function that later caused death?

Most of the evidence points to a flexed thoracic posture as yet another sign of a decline in physical function that heralds the grim reaper. In a later study on the San Bernadino cohort (now up to 1578 participants), people with a flexed thoracic spinal posture also had weaker grip strength, rose from a chair less quickly and were more likely to have to use their hands to help get up a from a chair [4]. These are all factors that have been found to independently increase risk of death.

 

Posture and falls

Does being hunched over make a person more likely to fall? In the San Bernadino cohort, hyperkyphotic individuals were 1.38x more likely to report a recent injurious fall [5]. Another cohort of 72 individuals with an average age of 77.8 had their posture measured and then were followed for a year during which 35% reported an injurious fall.  Those who required one or more 1.7cm blocks behind their head to lie flat had 3.2x as many falls as those who didn’t [6]. These individuals had a rigid hyperkyphosis, meaning their spine had rounded forward either as a result vertebral fractures or connective tissue stiffness and they couldn’t straighten up if they wanted to.

Are these people falling because they are hunched over? Or are they hunched over because they are at risk of falling?

A South Korean research group led by Jae Choi asked 50 health individuals to either stand up straight or bend forward with 30 degrees of flexion at the hip and knee while they stood on a platform that tilted unexpectedly [7]. They found that reaction time, especially in the backward direction, was faster when people were flexed forward [7]. (Backwards is the direction in which older individuals have the most pronounced difficulty.) This study suggests that crouching down is actually a natural and beneficial response to poor balance that makes people more stable (think of the natural postural response to walking on ice). It is worth noting that the participants in this study were young and healthy and they were asked to flex at the hip and knee and not at the upper back. We can confidently conclude that for young healthy people, crouching down makes them more stable but this is not the same as an older person being stooped over from a rigid hyperkyphosis in the upper back.

 

Posture and organ function

Did your mother ever say “Sit up straight or your insides might fall out?”

A quick review of the human pelvic bones and how our big headed babies are born reminds one that the bottom end of the pelvis is open. An upright posture includes a pelvis that is tipped forward, allowing some of the weight of the organs to rest on the front part of the inside of the pelvis. Pelvic organ prolapse, refers to a condition affecting women in which the internal organs press down on the pelvic floor muscles and begin to work their way out of the birth canal. In mild cases only part of the bladder, urethra, vagina, uterus hangs down, but in severe cases one or several of these structures can partially hang outside of the body. Among a cohort of 363 women, this pelvic organ prolapse was 3.2x more likely in those with either a lack of arch in the lower back (flat back)  and/or a hunched upper back (hyperkyphosis) [8].

Slump forward and take a big breath. Now sit up straight and take a big breath. Its no surprise that this study on older individuals with hyperkyphosis found that those where the more hunched over a person was, the less air they could bring into their lungs [9]. However, this impairment was not correlated with the likelihood of developing acute respiratory distress [9].

 

How do you get bad posture?

Why do you have bad posture? Do you slump because of your work station, your depression, or because low bone density caused your vertebra to fracture while picking up the laundry? Your posture is the result of the confluence of your genetics, strength, flexibility, habits, bone density, mood and conscious efforts. With the exception of Scheuermann’s disease [10], my observation is that most people have generally poor posture throughout life that becomes more rigid over time and progresses into very bad posture as they become weaker in their upper back muscles and/or accumulate vertebral wedge fractures due to low bone density.

Upper back weakness, and a flexed posture increase the risk of a vertebral wedge fracture which then causes a more hunched over posture and even greater risk of further fracture in a feed forward cycle [1]. Many of these fractures occur during activities of daily living such as picking up the laundry basket or emptying the dishwasher with a rounded back. Vertebral wedge fractures are relatively common. Among 15,570 Europeans between the ages of 50 and 79, 12% had radiographic signs of vertebral fracture [11]. Rates were as high as 20% in Scandinavian countries [11].

For those stooped over, there is still hope. Wendy Katzman has published several studies showing that in the elderly with hyperkyphosis, twice weekly physical therapy exercises for several months can produce small but measurable improvements [12]. But don’t wait, the longer you spend hunched over, the harder it is to correct!

Conclusion

A hyperkyphotic posture is indeed linked to an increased risk of falls, pelvic prolapse, poor lung function and death. Although death is unlikely to be directly caused by poor posture, stooping over is yet another sign of a decline predicting doom and the activities such as strength training that can reverse poor posture have been independently proven to increase ones years of health lifespan [13]. In the end, your conscious efforts to sit and stand up straight, combined with your strength and flexibility training over your lifespan have a huge influence on whether you end up doubled over in your dotage.

“I want to get old gracefully, I want to have good posture” -Sting

 

References

1. 2010 Katzmann- Age-Related Hyperkyphosis: Its Causes, Consequences, and
   Management
2. 1999 Kado. Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med.
3. 2004 Kado. Hyperkyphotic posture predicts mortality in older community-dwelling men and women: a prospective study. J Am Geriatr Soc
4. 2005 Kado. Hyperkyphotic posture and poor physical functional ability in older community-dwelling men and women: the Rancho Bernardo study. 
5. 2007 Kado. Hyperkyphotic posture and risk of injurious falls in older persons: the Rancho Bernardo Study.
6. 2017 McDaniels-Davidson. Kyphosis and incident falls among community-dwelling older adults.
7. 2011 Jae Choi. Does the Kyphotic Change Decrease the Risk of Fall?
8. 2000 Mattox. Abnormal spinal curvature and its relationship to pelvic organ prolapse
9. 2015 Lee. Clinical Features and Outcomes of Respiratory Complications in Patients with Thoracic Hyperkyphosis. Lung. 
10. Scheuermann’s disease is a condition in which the vertebra grow faster on the back side than the front, resulting in wedge shaped vertebra and thoracic hyperkyphosis. While wikipedia makes it sound inevitable and irreversible, mild to moderate cases can be corrected with early and aggressive physical therapy. I once had a spinal x-ray as part of a research study and the radiologist diagnosed me with scheurmann’s disease due to the wedge shape of my vertebra. In spite of this, I have excellent posture due to my frequent postural corrections and paraspinal muscle strength, the vertebral discs have compensated for the wedge shaped vertebrae.
11. 1996 O’Neil. The prevalence of vertebral deformity in European men and women: The european vertebral osteoporosis study. JBMR. 
12. 2014 Bansal. Exercise for improving age-related hyperkyphotic posture: a systematic review.
13. 2012 Gremeaux- Exercise and Longevity. 

Images

1. Cover: Flickr image “Thinkers” by Osbornb. Cropped. Creative Commons BY 2.0 
2. Flickr image “Determined” by Matthew G. Unmodified. Creative Commons BY 2.0.
3. Flickr image “Chimp Thinker” by Aaron Logan. Unmodified. Creative Commons BY 2.0 Unmodified
4. 2010 Katzmann- Age-Related Hyperkyphosis: Its Causes, Consequences, and
   Management
5. Flickr image “The Grim Reaper” by Paul Kline. Unmodified. Creative Commons BY 2.0
6. Flickr Image “Florida Fall Foliage” by Olin Gilbert. Unmodified. Creative Commons BY 2.0
7. Flickr Image “Early Labor” by Sarah Stewart. Unmodified. Creative Commons BY 2.0
8. A Chinese watercolor painting I saw in a bathroom.