Back bothering you by the end of the day? Neck killing you for no apparent reason? Struggling to sit up straight? Chances are you’re dealing with the consequences of a lousy foundation, some poor framing/support, or both. Uneven hips, crooked or unduly curved spine, muscle imbalance or spasticity — these conditions, if left unaddressed, often lead to something akin to that Tower in Italy. But fear not, crooked reader in pain, equipment and some new habits — rather than surgery — can probably ease the discomfort and put a smile on your face.
Problems and Causes
Posture problems are common for wheelchair users, with costs ranging from chronic pain and fatigue to permanent skeletal changes. What we see are crooked bodies often leaning off-kilter in their chairs. Or we see bodies slouched in the lounge position or bent forward like the 2,000-year-old man. What we feel is pain — often in the low back, neck, shoulders or butt — commonly accompanied by frustration and self-consciousness about appearance.
Normal spines curve outward a bit in the thoracic (middle back) region and slightly inward in both the cervical and lumbar areas. The goal is to maintain those natural curves. Think of your chair, chair back and cushion as bracing and support for the skeleton and accessible muscle mass. If the hips and spine are askew and alter those natural curves, the result will usually be pain, as well as various other problems.
Postural pain is often the result of muscles trying to do jobs they aren’t designed to do, or trying to compensate for nonfunctional muscles due to paralysis or weakness. Asking muscles responsible for movement to maintain trunk stability is like asking a defensive tackle to play quarterback: It not only doesn’t work very well, but is also painful to watch, even more so to experience. And if movement muscles are holding the body straight, they’re not available to facilitate mobility. The result? More pain and less function. In addition, muscles function best at their proper length. Poor posture due to slouching often stretches some muscles and causes others to shorten and weaken. Over time, those weaknesses and imbalances increase, as do the problems they cause.
Some wheelers develop scoliosis (lateral curving of the spine) or kyphosis (curving of the spine or increase in back curve, resulting in a hunchback or slouching posture) — often in a very short time. Others deal with overdeveloped muscles throughout the front of the upper body from wheeling and lifting and reaching forward, while the muscles throughout the back of the torso and arms are little used and underdeveloped leading to atrophy and problematic imbalances. Asymmetrical (side-to-side) muscle imbalances or spasticity may come as part of the injury package and routinely reposition the body, often in painful and very awkward positions. As a nasty bonus, any or all of those problems also increase the risk of skin and respiratory problems.
Lack of trunk and lower back muscles to pull the chest back — or scooting forward in the chair in an attempt to gain stability — can put the body in a constant slump, with both the butt and the neck out away from the chair back. Trunk muscle imbalances, gravity or spasticity can pull the body to one side or the other, usually lowering one shoulder and elevating the other. Inactivity or lack of exercising can drastically decrease physical fitness, leading to fatigue or chronic pain. Habitual functional activities done the same way every day (hooking the same arm on the chair back) can cause contractures and exacerbate muscle imbalances.
Poorly fitted equipment (wheelchair, cushion or back) or other factors — such as working on a keyboard that is too low, too high or too far away; always leaning forward on the same elbow while talking on the phone; always sleeping in the same position; or crossing the same leg — these can also create or add problems.
If you’re reading this, you’re probably acquainted with sitting crooked, for whatever reason. Aside from the pain that uneven weight distribution on the butt causes, you’re also at risk for skin sores. If you’re slumping or slouching, your lungs are probably working harder because your posture is decreasing lung capacity. Posture issues are often a pain in the neck — quite literally. When you scoot your butt forward and lie back a bit in search of pain relief, you only increase the pain and further undermine posture.
Importance of Self-Evaluation
Your goal should be to maintain those natural curves as much as possible, compensating for muscle imbalances or skeletal irregularities with a properly configured chair, cushion, back and other equipment to provide adequate trunk support, stability and alignment — so no muscle groups fatigue too quickly or generate excessive pain.
Start by asking and honestly answering a few questions:
Do you have chronic pain in the neck, lower or upper back? Trunk? Shoulders?
More fatigue in the trunk and back than in arms or shoulders?
Are you sitting crooked — leaning to one side or the other? Is one hip higher than the other? One hip or knee more forward than the other?
Always leaning a bit forward? Have balance problems? Always falling to one side? Using hands and arms for support?
Any difficulty breathing or trouble getting full breaths?
Do the mirror check to visually document multiple problems:
When facing a full-length mirror, is more of the chair back visible on one side than the other? Do the hips appear to be level or tilting in a specific direction? Is one higher than the other? Does your waistband appear to be level? Do shirt stripes go straight up and down or straight across? What about the shoulders? Is the head directly above the pelvis or is the torso somewhat askew?
When you turn and look at your profile in the mirror, do the ear lobe, shoulder joint and hip joint form a straight vertical line above the chair axle? If not, the entire foundation sits on shaky ground.
It’s not always easy to recognize small, incremental changes in posture, which over time can become big problems. Make a constant and conscious effort to observe and evaluate honestly. Think of a “yes” to any of those questions — or failing the mirror test — as a wake-up call and motivation to seek an evaluation by a physical or occupational therapist or physician trained in spinal cord injury.
When I was planning this story, I foolishly assumed I could identify the five most common posture problems and offer a half page or so of solutions for each. Way too simplistic. Consulting with a seating expert such as a physical or occupational therapist is essential, as self-diagnosis may simply make matters worse, especially if you misdiagnose the cause(s) of posture problems or trunk pain.
“There are just too many variables,” says PT Cindy Smith, who has worked for 25 years with wheelers living in the community. “Is the problem due to muscle tightness? Is it an orthopedic problem such as kyphosis? Is it structural, the result of skin flap or bone shaving surgery following sores? Lousy posture might be due to environmental factors, such as an ill-placed keyboard. It might be due to habits, such as always leaning to one side or the other because that’s where you’ve mounted your smartphone for texting and talking. A great number of things affect posture.”
Think of the spine as a stack of building blocks. Stack them slightly off-kilter and they’ll probably be OK, but putting some weight on them will cause problems to develop over time. Gravity eventually takes its toll, often in the form of a slow deterioration of those building blocks. Lack of trunk muscles — or just minor trunk muscle imbalances — can, over the course of years, also cause major problems. Just like rivers create canyons, gravity and time create arthritis, posture problems, chronic pain, decreased energy and possible skin problems. Gravity is not your friend.
“It’s hard to get people to accept that it’s better to have their hips back and their backs up against the chair back,” Smith asserts. Why? “Because it provides better weight and pressure distribution as well as support for the entire back. People come in with kyphosis (that slouching and rounding of the back) and the only thing hitting the chair is the back of their butt and the middle of their back.”
Most people are uncertain as to exactly what’s causing the problem and can easily employ counterproductive solutions. Some problems call for accommodation, others for compensation or corrections, and some can be fixed with a change of habits like phone or keyboard location. Prudence suggests consulting with a professional to sort out variables and steer you toward a solution.
Aids for Getting Straight
Smith is a strong advocate for addressing those changes in the body that require new or different equipment to provide an improved foundation and more appropriate torso framing or bracing. Many solutions exist:
Cushions serve three purposes, says Smith: stability, postural control and pressure relief. Some cushions provide pressure relief or comfort, some help with positioning or stability, and some provide all of those and are coded for reimbursement accordingly.
Solid chair backs can provide necessary support to compensate for trunk weakness, keeping straight without weakening useful muscle mass. Solid backs of proper height — and/or lateral supports — may also reduce pain and fatigue by compensating for irregularities in the hips and torso.
Contoured backs — or backs with lateral supports or “wings” — can support torsos that lack adequate muscle mass and can help counteract spasticity and/or side-to-side muscle imbalances. They can also stabilize the pelvis of those blessed with strong trunk muscles, allowing them to reach forward or side-to-side with much greater stability and function.
Corsets can also help counteract muscle imbalances, straighten the trunk, reduce fatigue, assist with balance and allow improved function with greater stability. Wearing a corset may provide the trunk stability necessary to make sports or other activities fun rather than work.
Chest belts can ensure stability and help with balance, reduce pain and fatigue and help correct hip and torso irregularities.
Of course, it goes without saying that a properly fitted wheelchair is absolutely necessary to encourage and maintain good posture. Marty Ball, who helped found TiLite and has decades of experience in the industry, is fond of saying that a wheelchair should fit like a glove. Custom fitting of wheelchairs demands working with a qualified seating specialist who understands wheelchair dynamics and takes proper measurements.
Addressing posture problems with appropriate changes may make sitting at a desk for hours feasible, making employment possible and life in general far more enjoyable.
Making changes will also change the way you feel in your chair. Changes require effort, and most crips are simply weary of adjusting and adapting. But many who diligently try lateral supports or corsets for a month or two, for instance, are apt to stick with them, not because they “need” them, but because the added support enables them to do more things.
Adapting and adjusting offer other payoffs as well: Reduced fatigue means more energy, decreased pain or fewer skin problems, reduction of spinal curvature, and un-slanting of hips. Good posture leads to a more even weight distribution, fewer potential skin problems, and safer driving. Sitting straight also affects the physics of the body and places it in a more efficient wheeling position. The sum is greater stability and more function.
How we look to others is a reflection of self-confidence and esteem. Sitting straight with posture mimicking the natural curves of the spine projects confidence, competence, positive self-image, strength and an overall more natural appearance.
Best of all, it makes you feel better.
Three Longtime Wheelers Search Out Solutions
George Kreye was concerned about the image he was projecting. “I looked terrible,” he recalls. “I was so crooked in my chair — and it really bothered me.” Kreye, a C5-6 quad, was about 20 years post-injury and still a practicing dermatologist when he realized this. Today he is 78. “Now I use a corset, a solid back with some lateral supports, and have wedges in my cushion and against one hip to even out my pelvis. All of them help a great deal. I feel — and look — much straighter and have more stability when reaching.” The trunk lateral supports and the hip wedge work together to keep both the pelvis and spine more aligned.
Chuck Holiday had multiple posture problems: scoliosis, asymmetrical trunk muscle strength and spasticity, kyphosis and pelvic obliquity (one hip higher than the other). “The spinal curves, along with some crutch and daily treadmill walking for 20 years, eventually wreaked havoc with my sitting posture, leaving me with chronic low back pain, very uneven hips and a crooked torso.”
Holliday, now 67, began using a corset about two years post-injury, and though he initially resented it, he says he soon found it a useful tool for fatigue control and stability. “Besides,” he adds, “I looked at least five pounds thinner and it made walking easier on my back.” Next came a solid back and lateral supports — two up near the armpits and one against the left thigh — to deal with worsening scoliosis and to further straighten the pelvis. By this time he was working full time. Although the supports were initially bothersome and confining, Holliday came to appreciate how they kept him straighter and feeling less fatigued after hours at a keyboard.
Jack Dahlberg has dealt with scoliosis for almost as long as he’s been injured. “Photos from the 1970s show me sitting off-kilter, with more weight on my right hip. It put me off-center and off-balance for wheeling in my chair. When I was travelling constantly, I didn’t want to hassle with removing a solid back with laterals and stowing it, so I stuck with a sling back and my posture got progressively more problematic, affecting balance, function and reaching ability.
Dahlberg switched to a power chair and tried a solid back and laterals but kept breaking them, so he settled for a clamshell back, which gave him more support. “I switched cushions to straighten out my hips and deal with a crooked pelvis and also began using some wedging to help keep me straight. I’m now quite picky about equipment, making sure it fits and works well — and I know enough to pick a chair that’s compatible with the necessary supports.
“I have yet to find the perfect answer,” he says, “but I’m constantly monitoring my posture.”