Fix the Posture

 

Are we so beaten down by life, we have to stand that way too?

— Upper Body Posture
       I. Side View
       II. Front and Back Views
— Lower Body Posture
— Standing Tall and Determination to Change
— The 3 Types of Faulty Body Posture in Side View and Exercises
— Postural Exercises in Brief

Upper Body Posture

I. Faulty Postures in Side View: All three of the main types of faulty posture seen in side or lateral view — Flat Back, Sway Back and Kephotic-Lordotic — have some degree of excessive forward curve of the upper back that results in the "dead weight" of the head being perched out over the chest instead of on top of the shoulders and squarely supported by the spinal column. In this forward position, the head's center of gravity (same as center of mass in a uniform gravitational field as on earth) lies significantly ahead of the neck's base of support at the top of the thoracic spine. This is like holding an 8 to 10 pound bowling ball several inches out in front of you — all day, every day — where it feels much heavier than if it was held close to the body. This unbalanced head position increases the tendency of the head to fall forward and the neck to bend with it unless the muscles at the back of the neck (the neck extensors that pull/bend the neck back) work harder and need to stay tight all the time. If chronically tight neck muscles are injured in an accident or strained by overuse, they do not heal well because of lack of rest and reduced blood circulation (tightness tends to keep the blood "squeezed out" of the muscle). Poor healing weakens muscles and keeps them inflamed, irritated, and prone to reinjury. With each new incident of neck strain, rear neck muscles weaken further. Eventually daily activities, use of arms, and neck movements that would never have caused neck pain before, now do. To avoid further pain, many sufferers limit activities and neck range of motion (R.O.M). Doing less and avoiding neck movement leads to more weakness, neck stiffness, and reinjury. Eventually back neck extensors atrophy from over-work caused by forward head posture and chronic damage from muscle strains that never completely heal. All this makes recovery even more difficult.
    Meanwhile the front neck muscles (the neck flexors) that bend the neck forward and help balance the head by preventing it from falling backward, have little to do, since in slouched posture the head is already held forward. The front neck flexors weaken and atrophy from disuse (not enough work) rather than from overwork like the back neck extensors. The weakness of front neck muscles is why many chronic neck pain sufferers are unable to lift their heads when lying on their backs. (I couldn't.) For details see How Slouched Posture Causes Neck, Shoulder and Upper Back Pain.

Persistent hunching of the upper back combined with rounding forward of the shoulders also causes:

• Stretching and weakness of upper and mid back extensors (in rib cage/thoracic spine region), which are the large group of back muscles that pull the spine erect and oppose the bending forward action of front abdominal muscles;
• Adaptive shortening and tightness of front chest muscles (Pectoralis Major and Pectoralis Minor), which makes raising and expanding the chest more difficult.
• Widening of the distance between shoulder blades, which causes stretching and weakening of the Rhomboids, and Middle and Lower Trapezius — the muscles that anchor the shoulder blades in back to the thoracic spinal column.   see illustration—> —>
• Stretching and weakening of the Levator Scapula, but shortening of the Upper Trapezius. These are the two muscles that suspend the shoulder blades from the cervical (neck) spine, and they become increasingly more important stabilizers of the shoulder blades when the upper body is hunched over and shoulders are rounded forward; and the stretched, weakened Rhomboids, and Middle and Lower Trapezius, no longer firmly anchor the shoulder blades to the more sturdy thoracic spine. Though the Upper Trapezius is shortened and tighter, and the Levator Scapula is elongated and weak, both together are not strong enough to take over the work of the other shoulder blade stabilizers. Unfortunately the pair can't avoid their anatomical role of suspending the shoulder blades, so both muscles end up being pulled down by the weight of the shoulder blades plus the arms that hang from the upper outside corners (shoulder blade houses the shoulder joint). This constant traction produces irritation and hyperactivity of the Upper Trapezius and Levator; they keep trying to raise the shoulders up toward the ears. Weight-bearing activity with the arms adds to the load and makes spasm more likely. Focal points of hyperactivity are felt as knots/trigger points especially at the levator scapula's point of attachment to the shoulder blade (red X in illustration at upper right) and back of the neck. The fleshy bodies of both muscles become sore and prone to spasm. In the long term, areas of muscle attachment on cervical vertebra and nearby joints, such as facet joints, become inflamed and sore; facet joint pain from pre-existing arthritic degeneration may worsen. In some cases (like mine) neck muscle and joint inflammation become so severe that joint mobilization and therapeutic massage, rather than relaxing the neck, only flares pain more. (For more detail see How Slouched Posture causes Neck, Shoulder and Upper Back Pain.)

Improved Upper Body Posture brings the shoulder blades closer together and does not allow stretching/weakening of the rhomboids or the middle and lower trapezius, all three of which transmit forces from lifting/pushing/pulling weight with the arms to the more massive spinal column of the back. With good stabilization of shoulder blades by these larger muscles, very little force is transmitted to the more delicate cervical (neck) spine by the upper trapezius and levator scapula, even when heavy loads are lifted.

An Exception: Depressed or Droopy Shoulder Posture

Sometimes it's the Lower Trapezius and lower fibers of the Serratus Anterior that are too strong and short (Lower Trap dominance) while the Upper Trapezius is elongated and weak. The neck may seem very long and the shoulders slope down more steeply than usual. The best clue to depressed shoulder is that the collar bones are horizontal or slope down toward the shoulder joint; while in back the shoulder blades are held too low. Sometimes it's just one shoulder that's depressed, usually the shoulder of the dominant arm, or whichever one holds the shoulder strap for a heavy purse or briefcase. In depressed shoulders, a painful condition called Thoracic Outlet Syndrome is more common. (Symptoms of Thoracic Outlet Syndrome include waking from sleep with numbness, tingling, weakness of hands and arms.) Thoracic outlet syndrome results from compression of the brachial nerves or plexus (the cords of converging sensory and motor nerves of the arms that run from nerve roots in the cervical spine, down the neck and through a narrow passageway in the shoulder to the arms.). There are 3 areas in the shoulder where space is particularly tight, making brachial compression more likely. One of those spaces is between the collar bone and first rib. Thus, if a collar bone is held too low as in depressed shoulders, it may press down on the brachial nerves and crush them against the first rib. At the same time, the Upper Trapezius may try to protect the brachial nerves by involuntary contraction (protective spasm) in an attempt to raise the collar bone to relieve the nerve compression. But the upper trapezius is already compromised; it is elongated and weak from being pulled down by the stronger lower trapezius, so extra work makes for chronic pain, spasm and atrophy.
      (More information, references on Thoracic Outlet Syndrome and anatomical illustrations)

II. Faulty Postures in Front and Back Views:
Complicating any of the above faulty postures may be excessive differences or asymmetry between left and right halves of the body. Many right-handed people tend to have the following slightasymmetries: lower right shoulder and shoulder blade, deviation of spine toward the left ("C"-shaped curve), higher right hip, and the right gluteus medius weaker. (ref: Kendall et al. 2005, pp. 74 - 77) These asymmetries may be worsened by the following: habitually standing with more weight on the right leg and with the right hip higher and jutting to the side (I stood like this all the time without thinking about it – see illustration below);  sitting with left leg and foot folded under the butt; reading in bed while lying on the left side and propped up by the left elbow; and holding a baby exclusively on the right hip. These postures displace the spine to the left and accentuate the "C" curve. Left-handed people tend to have the opposite asymmetries.

Excessive asymmetry may cause chronic pain. Sometimes an inciting incident such as one-sided spasm of the lower back leads over time to postural asymmetry between right and left sides. "With a back spasm, the pull will be so strong and abrupt the body has to drop the shoulder and lean the head away. ...as [an unconscious] protective mechanism" (Carey, 2005, p.75). But an inciting incident is not needed to develop postural asymmetry. Many people, when standing still, habitually shift their weight to the same hip and leg every time without realizing. In time it becomes easy to believe that the results of that way of standing – the low shoulder and "short leg"- are inherited or developmental, but it's really the result of long term habits in standing, sitting and lying that exaggerate handedness asymmetries. [Of course there really can be structural leg length discrepancies - see an orthopedist for diagnosis and treatment.]
Regardless of the cause, such postural asymmetry can lead to back, hip or leg/foot pain. In right-handed persons, the right lateral trunk muscles may be compressed between a low shoulder and a raised hip. If chronic, the muscles along the compressed side of the trunk become shortened, tight and prone to spasm when turning or twisting in daily activities. Due to the low shoulder, the neck and head may tilt down to the right; however, because the brain likes the head and eyes to be level, the neck will usually tilt in the opposite direction, which returns the head upright but also widens the space between shoulder and neck (see illustration: Asymmetric Upper Body-A). Sometimes the head and neck will also tilt down to the right, resulting in pain and tightness of the left lateral neck muscles, which are under increased stress as they try to support the off-balance head (Asymmetric Upper Body-A).

"Usually, shoulder correction tends to follow correction of lateral pelvic tilt..." (Kendall et al.).

To help with correction:
For right handers, 1) stretch tight, short right lateral truck muscles with gentle side bends to the left. Do not bounce but use steady, gentle, pressure for 30 seconds to a minute until tightness is lessened and range of motion is restored to the right side. 2) If stretching is not enough to maintain better vertical alignment then strengthen weak, elongated left lateral trunk muscles. Hold a weight (such as dumbbells or kettleball) in the right hand and bend laterally half-way only, down to the right. Then come back up to vertical with the effort/contraction coming from along the left side of trunk. 3) When alignment and strength are equalized between the right and left, then pay equal attention to strengthening both sides.

For left-handers, do the opposite–1) stretch the left side with side bends to the right. 2) Strengthen right side by bending half-way only to left and coming up to vertical with weights in left hand.

For a high, prominent, right hip, stretch the left lateral thigh muscles.
For a high, prominent, left hip, stretch the right lateral thigh muscles. (from Kendal et al.)

If one-sided hip pain is a problem, then strengthen the gluteus medius muscle. Frequently standing with one hip thrust to the side causes stretched and weakened hip-stabilizing muscles. [I always had right hip pain whenever I walked around the block] then strengthen the gluteus medius. See image of posterior hip muscles created by Beth Ohara. Doing plenty of squats, good-mornings and sit-to-stands, while "squeezing" the gluts on the way up helps. See the videos here for more gluteus medius strengthening and hip stabilization exercises 

And most important — always remember to stand with weight evenly distributed between right and left legs. 

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Exercises for Upper Body Posture:

— Goals:

• Bring the upper body back over the hips for firm support. (Most important for Flat and Swayback posture.) This may include correction of pelvic tilt, strengthening of low and mid-back extensors, and strengthening of abdominals depending on posture type. (see Lower Body posture below)
• Reduce Postural Kephosis/Hunching of Thoracic Spine by stretching tight front chest muscles andstrengthening weak Upper and Mid-Back Extensors.
• Improve Shoulder Blade Stabilization to Thoracic Spine by strengthening Rhomboids, and Lower and Middle Trapezius. This takes stress off the Upper Trapezius and Levator Scapula (neck muscles).
• Reduce asymmetry between right and left sides of the body by always standing with weight evenly distributed over both feet, always sitting with both feet on the floor, not favoring one side over another when holding children or carrying heavy items, don't lie on one side in bed to read.
• Develop the habit of self-correcting posture during the process of strengthening postural muscles, and continue that habit after good postural muscle strength has been achieved and improved posture becomes easier to maintain.
• [For Depressed/Droopy Shoulder(s): Strengthen stabilizing function of Rhomboids and Middle Trapezius, strengthen and shorten Upper Trapezius, and Levator Scapula by reminding oneself to keep the shoulder(s) higher and more squared* but only if no pain. Shoulder shrugs with weights can be used to strengthen upper trapezius, but do not allow shoulder(s) to drop all the way down before the shrug. This is to increase strength in the shortened muscle and decrease downward range of motion. Release tight Lower Trapezius with stretches like Downward Dog]

*The following illustration shows how much I lift my right shoulder, which is slightly depressed, and the isometric strengthening of the surrounding musculature (while I observe my back in a 2-mirror set-up): 

Exercise Tips:

• Know your posture type. Posture at rest depends on the sum total of balances or imbalances in muscles and muscle groups that operate most joints of the body.
• Use your specific posture faults as a guide to help decide which muscles need strengthening and which need stretching. A general exercise class will probably not improve posture and may work against you.
• Picking the exercises that you like doing probably strengthens muscles that are already strong and doesn't help muscles that are weak; which worsens muscle imbalance.
• Don't just strengthen the muscles seen in frontal view such as those of the chest, front of shoulder, the abdominal 6-pack area, fronts of thighs (quadriceps) and upper arms (biceps); thatstretches and weakens the opposing muscles in back, which are responsible for keeping us erect and in good posture alignment. Give posterior muscles such as back extensors, gluts and triceps at least equal time, if not more, to compensate for the way we customarily use our bodies. (e.g. more bending forward than bending backward, more sitting than standing or walking, more rounding shoulders forward than lifting the chest and keeping shoulders back, more Bending head down instead of looking straight ahead, more bending elbows than keeping the arm straight.)

Slow Down for Stretching and Strengthening Exercises:

• Stretch in a slow, mindful manner. Quick or bouncy movements activate the stretch reflex, which causes immediate contraction of the stretched muscle—the muscle actively resists the stretch, which is the opposite of what one intends. Also, in bouncy stretches the extent of the stretch is uncontrolled and before one realizes, damage may already be done.
  Duration of stretches: Studies done in middle aged or younger adults show that a minimum hold of 30 seconds is best, while 60 seconds does not improve the outcome (ref). In adults older than 65, muscle response is best for a hold of 60 seconds (ref). Abstract from another study showed that..."12 x 15-, 6 x 30-, and 4 x 45-second single durations of active stretching were equally effective at increasing hamstring length when performed 3 days per week for 12 weeks [in young adults.]"
• Perform strengthening exercises slowly and mindfully to protect joints from sudden uncontrolled movement and to maintain correct postural alignment during the exercise. Also slow movements provide a better workout because — 1. the prime mover/agonist (the muscle responsible for the specific movement) isn't helped by momentum, and 2. the antagonist (the muscle on the other side of the joint that opposes the prime mover) can't just let go and relax all the way, but remains tense to steady the resistance or weight while slowly lengthening in an eccentric contractionto allow the agonist/prime mover to operate the joint. (A joint needs a pair of muscles or muscle groups on opposite sides. For example, to close the elbow, the biceps in front of upper arm contracts, while triceps at back of arm lengthens; and to open, the triceps contracts, while biceps lengthens). Eccentric contraction may yield greater gains in muscle strength. See the article, How eccentric training speeds muscle strength gains. Arthur Jones, developer of the Nautilus exercise machine, advised two seconds to raise a weight and 4 seconds to lower it to take advantage of eccentric contraction or negative work as he called it. See also Strength gain through eccentric isotonic training without changes in clinical signs or blood markers "...strength training based on rapid concentric and slow eccentric contractions promotes functional adaptation with an increase in isotonic strength. ... a series of training sessions with increasing loads until reaching the maximum load provides a protective effect for the musculature, [to help avoid delayed onset muscle soreness]" versus a single session of localized exercise at 100% maximum load.
• If a workout causes pain around a joint, figure out why (or get an expert to help) before continuing. Reasons that a joint may be overstressed include: imbalance of prime mover and antagonist muscle pair, or weak joint stabilizer muscles for the intensity of exercise; unbalanced workouts; poor body mechanics; incorrect technique; or exercising when fatigued, which ups the risk of all the preceding. A little soreness in the "belly" of a muscle that disappears by the next workout is okay. Eccentric exercise may cause delayed onset muscle soreness in the belly of a muscle, but with rest, the muscle heals and quickly adapts to prevent damage and soreness when the exercise is repeated. See previous comments about eccentric exercise.

The Exercises:

— Posture Practice —> Remind oneself frequently to:

• First key practice: Squeeze/tense the muscles in the mid-back area to straighten and bring the upper body squarely over hips in sitting and standing. (Mainly for those with flat and sway backs. For those with hyper-lordotic backs, concentrate on lengthening the lumbar spine between bottom of ribcage and hips to lessen lordosis.)
• Second key practice: along with straightening the mid-back area, regularly take a few slow and complete breaths to expand the chest to full capacity. (Try inhaling to a count of 10 and exhaling to a count of 10.) This naturally gives a slight lift to the rib cage, reduces excessive rounding of the thoracic spine (if it's still flexible), helps bring the neck and head back over the shoulders and in line with the spinal column and stretches tight chest muscles. (see Standing Tall). Notice how good it feels to take a deep breath when the bottom of the rib cage is not buried in the abdomen.
• Third key practice: Correct faulty posture habits that tend to worsen bilateral asymmetry. Stand with weight evenly distributed over both feet*, and keep pelvis level. Sit with back straight and both feet on the floor, not one leg folded under the butt or one leg crossed over the other. Do not lie on one side in bed to read. For mothers and babysitters: alternate sides when holding babies on the hip.
  *Also make sure weight is distributed evenly between ball and heel of each foot.
• When lifting, pulling or pushing weight, concentrate on keeping shoulder blade movement controlled.[I concentrate on doing a lift as if my shoulder blades were doing the work.] But do not impede their normal movement, which is necessary to keep the head of the upper arm bone (the humerus) centered in its socket (centrated). Observe your back in a 2-mirror set-up and notice the movement of the shoulder blades as you lift your arms to the sides and up. If you use a light weight, you might notice how particular back muscles strain to stabilize the shoulder blades as they pivot apart and glide to the sides. It is important that the back muscles be strong enough to stabilize the shoulder blades; otherwise the shoulder blades and the weight of the arms drags on the two neck muscles – the upper trapezius and levator scapula – that suspend the shoulder blades from the cervical spine.
  
  
  
• Keep thumbs facing forward when hands are at one's side. If backs of the hands usually face forward, then the side of the arm is actually twisted to the front, and the head of the upper arm bone is internally rotated forward in the shoulder socket. If habitual, the back of the rotator cuff/joint capsule complex becomes over-stretched and weak; the front becomes too short and tight. Try the Thumbs Up Exercise to stretch tight front shoulder muscles and help balance muscles and tendons that anchor and center the humeral head in the shallow shoulder socket.)

—Fix the Shoulder Blades Exercise: a generally pain-free exercise that consists of pulling down and squeezing together the shoulder blades, and then holding for an isometric contraction. Very importantly, a mirror set-up is used to provide visual feedback, which is needed because of difficulty in sensing activation of the correct muscles. This exercise strengthens lower and middle trapezius, and rhomboids; returns upper traps and levator scapula to their optimal lengths and helps them strengthen; and repositions shoulder blades. (the pull-down part is not for those with droopy/depressed shoulder syndrome) Corrects forward head and postural/flexible kephosis (rounded upper back that's not rigid). And eliminated my chronic neck, shoulder and upper back pain, inflammation and tightness within 2 to 3 months. See instructions and illustrations: Fix the Shoulder Blades Exercise.

— Prone "Y", "T", "W" and "L" Positions Exercise: Similar movements, as in Fix the Shoulder Blades Exercise, but done against gravity, which adds to difficulty. In brief: Lie prone (face down) on floor, place arms in one of the four positions, have thumbs pointing up and keep shoulders down away from ears, squeeze the shoulder blades together while lifting arms and chest. Hold a few seconds then lower the chest. See detailed instructions and the video at Fit And Busy Dad.com. Excellent for strengthening mid-back extensors, middle and lower trapezius and stretching chest muscles. See similar exercises in article by McNitt-Gray and Mathiyakom.

— Variant of prone exercise for Droopy/Depressed shoulders: Lie face down. Place hands on back of head, fingers interlaced. Squeeze shoulder blades together and lift arms off the floor. Elbows should not lift higher than wrists. Do not arch the neck. (adapted from Rick Olderman's book andMcNitt-Gray and Mathiyakom)

— Arm Slides: Face the Wall "Y" Corrective Exercise and Wall Angels

— Arm Slide variant for Droopy/Depressed Shoulder: when elbows are level with shoulder, shrug shoulders up toward ears to elevate shoulder blades. (adapted from Rick Olderman's book)

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Lower Body Posture:
      Maintaining improved upper body posture is much easier when the lower body is properly aligned. It is the lordotic/inward curve of the lower back that positions the upper body over the hips and allows a stable erect posture. (Other primates like chimpanzees don't have a lordotic curve in the lower back, only one long kephotic curve; mostly they knuckle–walk with a curved–over upper body.)
     The degree of lumbar lordosis is determined by the tilt of the pelvis. The tilt of the pelvis depends on the action and balance of hip extensors and flexors. Ultimately neck posture depends on lower body muscles that control the angle of hip and knee joints. Physical therapy for musculo-skeletal neck and shoulder pain should include correction of lower body posture. Initially, that may take more time, but treating piecemeal and having to repeat physical therapy later for the same problem (e.g. neck pain) or a different problem (e.g. frozen shoulder and torn rotator cuffs) that stems from the same root cause (poor posture) is a waste of time and money (the patient's, the government's and the insurance company's); and is a waste of one of the few opportunities a patient has to receive one-on-one help from a qualified professional. (for more on Improving Physical Therapy Practice: A Patient's View)

Lower body posture in profile is mainly determined by two factors:

    1. Tilt of the pelvis 
Figure 1. The pelvis is attached to the base of the lumbar spine by the Sacrum, a large, thick vertebra–like bone that connects to the curved plate–shaped Iliums of the pelvis via strong ligaments and two Sacroiliac Joints. These joints and ligamentous connections interlock the sacrum and iliums, which allow very little independent movement; in effect, both move as one. If the pelvis tilts forward, the sacrum, with lumbar spine attached, is also pulled forward resulting in excessive inward (lordotic or anterior) curve of the lower back. If the pelvis tilts backward, the sacrum and lower spine back are pulled backward, which results in straightening of the lumbar curve as seen in Flat Back Posture. See figure 2. below.


    2. Angle of hip and knee Joints Backward bending (extension) of the hips and knees is usually limited, which gives stability to the body in standing position because you can't "buckle backwards" (Kendall et al.) But in Swayback Posture the hips and knees have a backward bend (hyperextension), causing the pelvis to shift forward ahead of the feet. To prevent the entire body from falling forward, the upper trunk shifts backward to compensate, see illustration below: Swayback Posture, third from the left:

Figure 2. Effect of Pelvic Tilt and Angle of Hip and Knee Joints on Lower Body Posture

Pelvic tilt is controlled by four groups of muscles:

Figure 3. Muscles That Control Pelvic Tilt.
 A. Two opposing muscle groups attach to the anterior (front) half of the pelvis: 
    1) Abdominals (Rectus Abdominis, External oblique) exert upward pull on pelvis. 
    2) Hip Flexors (Rectus femoris, Tensor fasciae latae, Iliopsoas, Sartorius) exert downward pull.
 B. Two opposing muscle groups attach to the posterior (rear) half of pelvis:
    3) Low Back Extensors exert upward pull on the pelvis. 
    4) Hip Extensors (Gluteus maximus, Hamstrings) exert
                                                                                                  downward pull. 

<—— Pelvis tilts forward when
  Hip flexors pull front of pelvis   down, and low back extensors
  pull the rear of pelvis up.


        Pelvis tilts backwards ——>
        when abdominals pull front         of pelvis up, and back hip         extensors pull the rear of         pelvis down.            

With all four groups of muscles in balance, the pelvis is held in neutral position, giving the lower back a slightly lordotic (anterior) curve. This alignment of the lumbar vertebra results in 80 – 90% of upper body weight being supported by the column of thick round vertebral bodies and gel-filled discs between the vertebral bodies in a uniform manner, while the remaining weight (10 – 20 %) is supported by the more delicate rear facet joints. Excessive lordosis transfers too much weight/force to the rear facet joints, causing more pressure on rear facet joints —> osteophyte formation —> narrowing of nerve channels etc.; while a flat or kephotic lower back transfers too much force to the front of the vertebral bodies and front edges of the discs; causing the discs to wear unevenly and develop micro-tears in the over-stressed areas, which leads to premature loss of fluid and disc height. (see Pathophysiology of Low Back Pain and Sciatica in Medscape and More Effects of Slouched Posture – structure and mechanics of intervertebral discs and spinal injuries, and aging of the spine.)

When pelvic muscles are not balanced, the pelvis may tilt forward or backward depending on which muscle groups are too weak/elongated and which are too strong/shortened relative to their antagonist muscle group.

Types of Lower Body Posture and Specific Muscle Imbalances:

• Lordotic Back: Some or all the following imbalances contribute to a hyper–lordotic lumbar curve: Weak anterior abdominal muscles (esp. External Oblique) allow the anterior pelvis to tip down and forward. Tight hip flexor muscles (esp. the Iliopsoas) pull the anterior pelvis down and forward. Tight Low Back Extensors pull upward on the posterior pelvis and weak Hip Extensors cannot counter the pull. Also see Kephotic-Lordotic Illustration.
• Flat Back: Tight Hamstrings pull pelvis down in back (and elongated/weaker low back extensors allow it), thus producing posterior pelvic tilt, which straightens the normal lordotic curve. Strong abdominals pull up on anterior pelvis further accentuating posterior tilt and weak hip flexors allow it. Also see Flat Back Illustration.
• Sway Back: Short, tight Hamstrings pull down on posterior pelvis, tilting it backward and flattening the normal lordotic curve. Weak, elongated one-joint hip flexor, the iliopsoas, cannot oppose. The External Oblique abdominal is elongated and weakened from accommodating to the backward sway of the upper trunk. Also see Sway Back Illustration.

To correct pelvic tilt to neutral, the pelvis may be deliberately tilted frontward or backward depending on type of faulty posture: see pelvic tilt exercises. But if hip or back muscles are tight, changing pelvic tilt may seem impossible or may cause muscle tingling or soreness. Best to see a doctor in case of radiating nerve pain. Otherwise, specific exercises directed at the 4 muscle groups that determine pelvic tilt, either to help stretch over–tight, shortened muscles, or strengthen opposing weak, elongated muscles, are needed. The specific exercises to use depends on whether excessive anterior or posterior pelvic tilt needs to be corrected. See The Different Types of Faulty Posture... below.

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Standing Tall:

Before postural self-correction can begin in earnest, it's important to feel/understand what standing in an upright perpendicular position (⊥) is really like. What a surprise, when I realized that standing against a wall felt unnatural because my normal posture was, and always had been, leaning forward and bent at mid-back. No wonder I couldn't easily bring my head to touch the wall behind me and later would have neck pain from trying. Come to find out all I needed was to take a deep breath, which lifted my chest, reduced thoracic Kephosis and straightened my mid back. Amazingly simple, but I was so accustomed to my hunched posture, it never crossed my mind.

Also notice whether one's body weight is evenly distributed over the soles of both feet, from side to side, and front to back. More pressure on one foot than the other indicates asymmetry between the two sides of the body. ( see Faulty Postures in Front and Back Views) More pressure on the ball of the foot and big toe, indicates that one is leaning forward. "Forward Body" is a strain on the posterior muscles of the trunk and legs, which remain in constant contraction* as they try to keep the off-balance body from falling forward; the pelvis is pulled on by tight hamstrings and tilts backward in order to pull the lumbar spine and rest of upper body vertical. Perhaps being so used to rushing to get everything done, we don't even bother to straighten up but lean forward in anticipation, toward the direction we hope we are going with our lives (rather than going around in circles), and the habit sticks whether running, walking or standing still ....Maybe by bringing more balance to the way we stand, we will bring more balance and stability to our lives in general.

For a good demonstration of wall standing and ideal sitting posture:
See the video: How to Improve Your Posture — powered by ehow.

*Kendall et al.
(The hamstrings in particularly tighten when the body leans forward. Poke a finger into the back of the thigh and feel the muscle tighten as you lean forward slightly. Take care not to fall.)

Finding the Determination To Change:

Some people know they have poor posture and simply accept it.

        I've always had poor posture....It's just the way
        I stand....It's comfortable....It's me.

Others have poor posture, but believe they have good posture. After all... spouse, friends, doctors, physical therapists and exercise instructors have never said anything about poor posture; even though mom might have, but who listens to moms? And the bathroom mirror only provides a front view, which doesn't show a forward head or a hunched back, especially when we're focused on blemishes, bags under the eyes, beard hair or wrinkles (and for women, applying make-up to hide them). A photo doesn't often help because most are taken face–on also, though you might find a side view in an unposed group shot, but unflattering views are often dismissed and discarded ...along with any other evidence of an unattractive or unhealthy appearance that doesn't fit one'sself image (which may be unrealistic, and is resistant to change).

Accordingly, the first step is to really look at oneself from the front, back and side, and preferable while performing daily activities. But how many people have their own videographer? So instead, one must arrange for a two mirror set-up that shows side and back views (see such aset-up here); and then be completely honest with oneself in front of the mirror (tougher than you'd think).

To change one's posture, to change anything, means turning away from the old, comfortable ways one is accustomed to moving, interacting or just being in the world, and accepting a degree of short- term discomfort. This is not the muscle-soreness or getting-out-of-breath kind of discomfort (in fact it usually feels better to stand up straight) but the mindful, have-to-stick–to–it, will–power kind. Correcting posture doesn't have the intensity of aerobics or weight training, but does require persistence until the weak, stretched-out muscles strengthen and tighten up, which makes it so much easier to maintain improved posture without consciously tensing muscles all the time.

In some ways, weak, stretched-out postural muscles are like the elastic waistbands of old underwear. Over time, waistbands get stretched and loose, and underwear won't stay up. Since loose waistbands can't fix themselves, we throw out old underwear or use them for rags, and buy new ones. But loose, weak muscles can repair and tighten themselves. With the right exercise and correct use, muscles regain optimal length, strength and resistance to stretching.

And a caveat: once the work is done, and the muscles restored, if the slouching habit returns, so will poor posture. The body is dynamic, meaning it's always changing. One of the ways it changes is to adjust to how it's used. So we must try not to return to our old sloppy, permissive ways, but take on a new attitude of caring for our bodies as befits the marvelous vehicle that will carry us into the future.

Of course, to "get over the hump," to overcome the inertia of the status quo of things as they are, and also to change our often resistant self image, we need to have at least one great motivator and better if there are several. It helps if one has strong belief, backed up by reasons and evidence, that posture improvement is important and necessary. Those reasons may include: 1) reducing chronic musculo-skeletal pain, 2) delaying age-related spinal changes, 3) helping to prevent injuries, 4) improving appearance, and 5) changing one's life for the better. But even with such positives, change is difficult, especially for a future gain such as delaying spinal changes or prevention of a musculo-skeletal injury that may never have happened anyway. Sometimes the motivation needs to be more immediate such as reduction in existing chronic pain or desire to improve appearance. And sometimes there are rare epiphanies of self-awareness, such as when I'd given up finding help for my neck, and having glimpsed myself looking so old and bent over, I finally realized: that if nothing else in my life ever improves, I can at least fix my posture.

      Some of the benefits of frequent self-correction of posture:

• Serves as therapy for the neck by regularly reducing harmful loads on the cervical joints caused by poor head, neck and shoulder blade alignment.*
• Trains, strengthens, and keeps the postural stabilizing muscles at the optimal length while they are being used in everyday activities with the body in correct alignment.* (Trying to strengthen a poorly aligned body only reinforces the poor alignment.)
• Standing and sitting tall positively effects the way people feel about themselves and how they conduct their lives. Studies in both men and women show that briefly assuming an open and expansiveposture decreases the stress hormone cortisol, increases testosterone and increases feelings of power and tolerance for risk. A closed, contractive, submissive posture has the opposite effect. (Power posing: brief nonverbal displays affect neuroendocrine levels and risk tolerance. by Carney et al. )
• As reported by Muraven, Baumeister and Tice (Longitudinal Improvement of Self-Regulation Through Practice: Building Self-Control Strength Through Repeated Exercise, J. Social Psychology, 1999) Diligent self-correcting of posture over 2 weeks, strengthened self-control (willpower) and improved performance on unrelated tasks requiring self-control. (Of course it's not just posture self-correction that works; any long term attempt to change habitual behavior gives similar results. On the other hand, short term attempts to change habits deplete self-control and often fail, but even in failure, it's the practice, itself, that leads to improvement over the long run)

(*adapted from Gwendolen Jull) 


— Remind oneself frequently to:

• Keep the body evenly balanced between ball and heel of foot. (Especially important for those with foot and toe problems. When my forward leaning posture had improved, the enlarged arthritic, joint of my big toe (Hallux Rigidus) became much less painful.)
• Keep knees loose to avoid hyperextending both knees and hip. But don't bend/flex them too much!
• Bend/hinge at the hips, not at the waist and upper back, which rounds the spine. Keep the back straight, and use a combination of hip bending and knee bending to get as low as one needs. The more flexible the hips (and looser the hamstrings), the less the knees need to bend, (and keepingknees behind toes takes stress off the knees and puts it on the thighs. Touch your front thigh muscles, the quadriceps, to feel the difference), The resulting movement looks like one is about to sit in a chair, with the butt sticking out to the rear — not a pretty maneuver, in fact it's called a "squat" which isn't a pretty name either — but strengthens thigh muscles, and avoids putting stress on the back. It's when the back is rounded in bending that it's most prone to injury. (see "Torso Flexion (bending forward) Loads and the Fatigue Failure of Human Lumbosacral Motion Segments" by Gallagher et al.)
• Include Upper Body Alignment: Keep the mid back straight and chest lifted without excessively arching the back (in both sitting and standing).

For more Tips on Improving Posture—see Spine Universe: "Maintaining a Healthy Spine—Your Posture" and "Maintain a Healthy Spine—Learn Proper Body Mechanics"

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Different Types of Faulty Posture Call for Different Corrective Exercises:Specific exercises can be helpful and are used to strengthen weak, over-stretched muscles and stretch short, tight muscles that are unbalanced by long term faulty posture. But the exercises must fit the specific type of faulty posture because there are different patterns of muscle imbalance seen in different postural misalignments. Determining the right exercises and how to do them correctly is the province of physical therapists and sometimes other physical fitness professionals. A thorough postural analysis generally consists of observing overall alignment of body segments and joints, testing and measuring for muscle strength, weakness, elongation or shortness, joint flexibility, stability and range of motion etc., and prescribing the necessary therapeutic exercises, as well as making sure the client performs them correctly and without harm to themselves.

—What follows is based on my limited, non-professional experience, and various text books and websites.

                Three Types of Faulty Posture in Profile:

Flat Back:

Figure 5. Flat Back Posture
Upper Body: Forward head, Upper thoracic spine curves forward, Lower thoracic straight. Shoulders rounded forward, and Shoulder Blade anchoring weak. Chestsunken, muscles between the ribs (intercostals), upper abdominals and accessory muscles of respiration such as the Pectorals are shortened and tight, so shallow breathing is the norm.
Lower Body: Pelvis tilted backward (tucked under) causing flat lower back/lumbar spine, and no butt; so pants and jeans sag in the rear.
Knees may be extended but not hyper-extended as in Swayback.
The Entire Body Leans Forward, only a bit, but very evident when one tries to stand straight against a wall. Body weight shifts to the forefoot causing increased strain. Calluses may form under the ball of the foot and/or the great toe, and may worsen toe conditions such as rigid great toe or hallux rigidus—degenerative arthritis of the first metatarsophalangeal joint.
(I have hallux rigidus that surgery 8 years ago couldn't correct, but posture correction has equalized body weight over the entire foot and calmed inflammation, greatly reducing toe pain.)

To Correct:

— For Upper Body: Fix the Shoulder Blade Exercise to improve forward head, pull shoulders back, strengthen shoulder blade anchoring, and free up neck motion. For tight chest muscles and upper abdominals, do Thumbs-Up and Bruegger Exercises, Wall Angels or Wall Standing Exercise, and frequently remind oneself to keep the chest lifted. Take some deep breaths during the day and notice how good it feels for the lungs to expand unimpeded when the chest is lifted. 
—For Lower Body: Loosen locked pelvis with hip extensor (Hamstring) stretches and practice forward pelvic tilts (in front of a mirror) or see this video Lower Back Lumbo-Pelvic Exercise. Get a sense of what it feels like to stand straight (at a 90 degree angle with the floor) by doing Wall Standing Exercises. Remind oneself often to straighten the mid-back. Strengthen lower back extensors with Multifidus and Back Extension Exercises. Remind oneself to relax the knees, and keep body weight evenly distributed between ball and heel of the feet. Strengthen hip flexors.

Sway Back:

Figure 6. Sway Back Posture
— Upper Body: Forward head; Long kyphosis of the Thoracic spine extends into lumbar region; Sunken chest; Shoulders, rounded forward and shoulder blade anchoring weak. Upper trunk shifted rearward.
— Lower Body: Pelvis tilts backward, causing flattening of the lumbar spine, but it doesn't appear flattened because the upper trunk shifts or sways to the rear. There is no body-wide forward tilt as in Flat Back. The shifting backwards of the upper trunk results in elongation and weakening of the External Oblique, an abdominal muscle, while upper fibers of the Internal Oblique, another abdominal muscle, are shortened and tight, to pull the rib cage back forward. Chest muscles (pectorals and intercostals) are short and tight. Hip Flexors, especially the Iliopsoas, are weak and can't oppose the pull of the short, tight Hamstrings, which tilt the pelvis backward.
Hips and Knees bend backwards in hyper-extension.

To Correct:

— For Upper Body: Fix the Shoulder Blade Exerciseto improve forward head, pull shoulders back, strengthen shoulder blade anchoring, and free up neck motion. For tight chest muscles and upper abdominals, do Thumbs-Up and Bruegger Exercises, Wall Angels or Wall Standing Exercise, and frequently remind oneself to keep the chest lifted. Take some deep breaths during the day and notice how good it feels for the lungs to expand unimpeded when the chest is lifted. 
— Lower Body: Loosen locked pelvis with hip extensor (Hamstring) stretches. Do Pelvic tiltsto increase pelvic flexibility. Strengthen External Oblique with Wall Standing Exercises, and Alternate Leg Raises (no double leg lifting), which also strengthens weak hip flexors. Or do other hip flexor strengthening exercises.
— The Knees: Keep reminding oneself to relax the knees and avoid hyperextension. Knee hyperextension may worsen postural bowlegs....

Figure 7 and 8. Postural Bowlegs is caused by internal rotation of the femurs toward the front of the hip. Thighs, knees and feet rotate inward toward the midline. The feet seem to collapse slightly inward (pronation) as body weight is borne more on the inside of the sole of the foot.
To Help Improve: Stand with feet 4 inches apart and toeing out slightly. Relax knees so not stiff or bent. Tighten buttocks to rotate legs slightly outward (until kneecaps face directly forward). Tighten muscles that lift the arches of the feet, rolling the weight slightly toward outer borders of feet.* It may not be possible to totally eliminate postural bow legs because there may be some structural factor as well. This is true of those in my family with bow legs. What is obvious, though, is that when they correct their sway back posture and stop hyperextending hips and knees, the appearance of their bow legs is much improved. Sometimes postural bowlegs is compensatory for Knock-Knees, which must be fixed first.* (See a physical therapist for help correcting both postural bowlegs and knock-knees.) 

*Kendall et al., Muscles: Testing and Function with Posture and Pain, 5th edition, 2005

Kephotic-Lordotic:

Figure 9. Kephotic-Lordotic Posture
— Upper Body: Forward head, Increased cervical spine lordosis ("C" curve) with Back neck extensors tight and short; Front neck flexors, elongated and weak.
Hyper Kephotic Thoracic spine with Upper Back Extensors elongated and weak; chest muscles, tight and short resulting in "sunken chest." Shoulders rounded forward, shoulder blades held farther apart and anchoring muscles are weak.
— Lower Body: Pelvis is tilted forward by short, tight lower back extensors, which leads to hyper-lordosis of the lumbar spine; while the hip extensors (hamstrings) are too weak and elongated to oppose. In front, the short, tight hip flexors (quadriceps) pull the pelvis down, tilting it forward as well, while the abdominals are too weak to oppose.

To Correct:

— For Upper Body: 
Fix the Shoulder Blade Exercise to improve forward head, pull shoulders back, strengthen shoulder blade anchoring, and free up neck motion. For tight chest muscles and upper abdominals, do Thumbs-Up andBruegger Exercises, Wall Angels or Wall Standing Exercise, and frequently remind oneself to keep the chest lifted. Take some deep breaths during the day and notice how good it feels for the lungs to expand unimpeded when the chest is lifted.
— For Lower Body:
First – correct anterior pelvic tilt: A) Stretch front hip flexors/quadriceps to allow the pelvis to tilt back more easily, and B) do Posterior Pelvic tilts to flatten the lumbar curve by tightening the front abdominals to pull up on the pelvis and tilt it backwards.
Second – strengthen weak, elongated external obliques see below for: A) Wall Standing,  B) Isometric "Abdominal Bracing Exercises"  3) Avoid crunches, which strengthen rectis abdominis (6-pack abs) but do nothing for the external obliques,
Third – strengthen gluts and hamstrings. Squats are extraordinary for improving strength of the posterior chain especially hip extensors and gluts. But make sure that hyper-lordotic lower back is corrected first.

*Kendall et al., Muscles: Testing and Function with Posture and Pain, 5th edition, 2005

Identifying Postural Type:

• Use an adjustable, swivel-type mirror in front and a full-length mirror behind to observe yourself in profile without turning the head. Such a mirror set-up also serves as a visual reminder and a way to practice good posture while your body sense (proprioception) is still adjusting to what good posture feels like. The mirrors are also used to monitor shoulder blade stabilization and correct activation of back muscles during the Fix the Shoulder Blades exercise and dumb bell lifts.
• Have someone take a photograph of your whole body, both a front and a profile view. A background with vertical lines, such as wallpaper or a fence, helps to show forward or side leaning tendencies. But a photograph is only helpful if it's an everyday posture, not an artificial pose. (I took posture photos of people in my exercise class. I told them to relax and assume their usual posture. Most of their postures looked great as they "posed" for me. But watching them during class exercises told a different story. As the instructor said, "You know at least that they know how to stand straight") Even better is a video taken during everyday activities because static posture in front of a camera may not accurately reflect a person's predominant posture during everyday movements. Watch for the tendency to look down at the ground while walking, tilting the head down while texting. and slouching while eating, working at the computer or watching TV.
• Observe postures of other family members. Postural tendencies seem to run in families. I tend to Flat Back, as my mother and her sisters did. My husband tends to Swayback as do his sisters. Of my children, two tend to Flat Back and one to Swayback. In particular, Swayback may by influenced by habitual leg/knee posture, especially bowed legs, which also runs in my husband's family.
• Posture changes from moment to moment, but tends to stay in a range. Look for one's predominant posture. Flat Back and Sway Back are similar. Some people with predominant flat back tend to switch to Sway Back when they are tired; they let their abdominals pouch out, and hyperextend their knees and hips, which throws their hips forward (I find myself doing this, though I tend to flat back posture.). Kephotic-Lordotic posture seems to be less common and those with it usually don't assume the other postures.

— Still having problems deciding? Then explore what your body can do. Try assuming the various faulty postures and observe the results in the two mirror set-up. 

• Sway back: stiffen and hyper-extend the knees, throw the hips forward and feel the mid to upper body shift back to balance, while the chest caves in and the very top of the back and head curve forward. Feel the slackening of the abdominal area. Note the long kephotic curve (the sway) from top of lumbar through mid to upper back.
• Flat back: Tilt pelvis backward and note the flattening of the lordotic curve of the lower back. Flatten the rest of the back but not the very top. Crane head forward. Do not throw hips forward. Stiffen the knees slightly but don't hyperextend.
• Kephotic-Lordotic: Accentuate all the natural spinal curves. Tilt pelvis forward and note increased lordotic curve in the lower back and pouching out of the entire abdominal area. Hunch mid to upper back to accentuate thoracic curve; and usually the lordotic curve of neck automatically increases to compensate (except in anatomical flattening of the cervical spine).

     Which posture is hardest? Which is easiest? (For me, Kephotic-Lordotic was most difficult. This was definitely not my posture. Decades of no lordotic curve had limited my pelvic flexibility. So Flat Back was easiest posture for me, but doing Sway Back was easy too, and in photos, I've seen myself with it—especially when holding my grandson.) Flat Back and Sway Back have an important similarity; they share a flattened lumbar curve, the result of a backward tilting pelvis (often from tight, short hamstrings). If a person with Flat Back hyper-extends his or her knees, and relaxes the external obliques, the rest of Sway Back posture is a natural consequence. 

Postural Exercises in Brief

Neck:

Strengthen Neck Flexors: Correct forward head/kephotic posture with Fix the Shoulder Bladeexercise. With this exercise the strengthening and rebalancing of neck flexors and neck extensors occurs naturally. Later when the neck is no longer painful, deep neck flexor exercises can be done if desired. See A byproduct of improving "Forward Head".... Also see the YouTube Video, Deep Neck Flexor Training, and also Professor Jull's Handbook, Whiplash Injury Recovery.

Thoracic Spine:

Strengthen Thoracic Spine Extensors and Reduce Kyphosis with Fix the Shoulder Blades exercise and Upper Back Extension exercises. Includes the prone "Y", "T", "W" and "L" positions for posture improvement. Also Bruegger Exercises.

Stretch Chest Muscles (Intercostals (Between the ribs), Abdominals and Accessory Muscles of Respiration such as Scalenes and Pectorals) with a few deep breaths, a couple times a day. Keep chest high as part of improving posture in standing and sitting. Do Thumbs-Up and Bruegger Exercises.

Low Back:

Strengthen Low Back Extensors (Flat Back and Sway Back): see Back Extension, Multifidus and Transversus Abdominis exercises.

Stretch Low Back Extensors with Posterior Pelvic tilts (Kyphotic-Lordotic only) On a firm padded surface, Lie on the back, bend knees and have feet flat on surface. Keep hands alongside head. Tilt the pelvis to flatten low back on the surface by pulling up and in with lower abdominals. Keeping low back flat, slide heels down to straighten legs as much as possible with back held flat. Slide one leg back at a time to return to knees bent position. (Do not use buttock muscles to tilt pelvis and do not lift feet from surface)*

Strengthen Lower Abdominals especially External Oblique (Kyphotic-Lordotic and Sway Back):
Wall–Standing Exercises (Can be done seated on a stool): Stand with back against a wall, with heels about 3 inches away. Place hands up beside head with elbows touching the wall. Tilt pelvis to flatten low back against the wall by pulling up and inward with the lower abdominal muscles. Firmly tighten the abdominals especially the lateral Obliques to shift the upper body forward and the pelvis back, and to "make the lower abdomen cave in." Keep arms in contact with wall and move slowly to a diagonally overhead position (like a wall angel exercise).
Isometric "Abdominal Bracing Exercises" but probably not in presence of hyperlordotic back, so needs to be done with neutral lower back curve. Not advised are Modified Sit-Ups like Trunk Curls or Crunches for two reasons, 1. Repeated and persistent trunk–flexion exercises may strengthen the Rectus Abdominis, but contributes to continued weakness of the External Oblique (Kendall et al) which needs to be strengthened to improve both Sway Back and Kephotic-Lordotic postures, and 2. Any kind of back flexion under loading puts undue stress on the lower back, may cause back pain, and especially should be avoided by post menopausal women due to their risk of osteoporosis and spinal compression fractures. (See Dr. Evan Osar's Abdominal Exercises/Dangers of Crunches) (also see discussion on Back Extension Exercises and Osteoporosis). See Dr. Evan Osar's article and video: The Crunch Free Ab Routine.

Back Hip Extensors:

Stretch Back Hip Extensors—Hamstrings (Flat Back and Sway Back): For a specific easy exercise: Hamstring Stretching from Duke Sports Medicine. But no extra exercise time is needed if a Deadlift Hamstring Stretch is used in the middle of chores that require bending down such as loading/unloading the dishwasher (the way I got my lumbar curve back!); and also provides practice for keeping the back straight rather than in a rounded "scared cat" posture that unbalances the back stabilizer muscles and stresses the intervertebral discs (causes posterior bulging of the disc).

Strengthen Back Hip Extensors—Gluts and Hamstrings (Kephotic–Lordotic Posture): Lie on the back with knees up. Keep the back in neutral position. Squeeze the Gluteus maximus (the butt cheeks) together. Then relax. Do 10 times, a couple times a day. A variation is to lie on the back, knees up and lift the butt off the floor keeping the back straight, as if making a bridge. See exactly how to perform this exercise in the video: Bridges for Glutes.
Squats are excellent for strengthening the entire posterior chain. They made a big difference in my life!

Front Hip Flexors:

Stretch Front Hip Flexors (for Kyphotic–Lordotic Posture): Side Lying Quadriceps Stretch. Lie on your right side with right elbow bent to support the side of your head. Bend the left knee and grab the left ankle with left hand. Mainly use the glut and hamstring muscles to pull the left thigh behind the body, but gently pull up left ankle toward butt to help. Very importantly, keep the lower back curve neutral. Do not arch the lower back. Hold gentle, but firm stretch for 1 minute. Repeat a few times per day as long as no soreness. See video of Side Lying Quad Stretch. Also see this video of a Kneeling Hip Flexor Stretch. The same hip flexor stretch can be found on the ABC of Fitness site.

Strengthen Front Hip Flexor Muscles at front of hip and thigh (for Flat Back and Sway Back): DO NOT DO THIS WHEN THERE'S BACK PAIN BECAUSE THIS EXERCISE WILL WORSEN IT AND CAN STRAIN THE LOW BACK. Walk in place or hold onto a support of some kind, and alternate raising each knee high enough so the thigh is horizontal to ground. Or while sitting in a chair with back supported, lift one knee with the hands as high as comfortable, let go and hold up for 10 seconds, then lower and lift the other knee, repeat 10 times. If no pain at all, trySeated Straight Leg Raises: Start seated on mat with back straight, knees bent, feet flat on the mat. Lean back keeping back straight, arms/hands behind in support, and extend one leg forward (knee may be slightly bent) and toes pointed (the other leg still bent with foot flat on mat). Tighten thigh muscle and lift the straight leg a few inches above the mat, hold a few seconds then lower. Repeat 5 times, then repeat with the other leg. With time increase reps until 20 have been reached. For extra strengthening light weight can be added to the ankle of the leg being lifted.

† warm up with a 5 to 10 minute walk or take a warm shower/bath.