Importance of Posture and Spine Alignment and Its Impact on Health-Related Quality of Life

Healthcare has established normal values for many health parameters such as blood pressure, cholesterol, blood glucose levels, body competition, etc.  When one varies outside these established normal measurements there are known associated health risks.  These health measures are commonly measured at a physical exam. But, what about measuring physical parameters such as rang of motion, posture and spinal alignment?

Normal spine alignment and posture is critical for optimal biomechanical function including spinal joint health and longevity.  There is an abundance of scientific literature substantiating the importance of optimal spine alignment and balance for normal activities of daily living, sports and physical performance, lifting and injury prevention. Additional research has shown how a loss of normal spine alignment and balance is associated with increased neck pain, back pain, headaches, dizziness, ect.

What is normal?

Before you can discuss what abnormal is you must establish where normal is supposed to be.  Normal spinal alignment when viewed form the front consists of the spine being in straight line with the skull being centered over the pelvis with the head, shoulders and pelvis being level.  Viewed from the side (sagittal alignment), there should be a lordotic curves (C-shaped curve) in the cervical and lumbar spine and kyphotic curves (reversed C-shaped curves) in the thoracic spine and sacrum[1].

Alignment is a different than balance, and a loss of sagittal balance is a major predictor of disability related to chronic back pain.  Sagittal balance is measured using sagittal vertical axis (SVA).  SVA is a measure of horizontal displacement of cervical spine measured from C7 compared to the sacrum. In the picture to the right the SVA is labeled as C7PL. In a normal (ideal spine) the upper cervical spine, lower cervical spine, lower thoracic spine and sacrum are all in a vertical alignment.  A “+SVA” occurs when the cervical spine displaced in front of the sacrum by more than 4 cm. When this occurs the abnormal position of the spine and posture is a high predictor of disability due to chronic back pain.

What if I’m abnormal?

Once normal spinal alignment is defined then we can discuss the consequences of being abnormal.  Anterior head translation (forward head posture) is correlated with increased likelihood of headaches, migraines, decreased cervical range of motion, chronic neck tension, etc.  Anterior head translation also has a strong correlation with temporal mandibular joint dysfunction[2].  Hypolordosis (decreased neck curve) and cervical kyphosis (reversal of the normal cervical curve) have been associated with increased neck pain[3].  Loss or reversals of cervical lordosis is also correlated to degenerative disc disease in the cervical spine. In a normal cervical spine approximately 1/3 of the weight of the head is loaded vertebral body and disc and 2/3rds is on the posterior column with the weight on the facet joints[1].  With a loss or reversal of the normal cervical curve the increased weight on disc leads to degenerative disc disease.  Additionally, the average adult head weighs between 12-15lbs, for every inch of anterior head translation the work required by posterior cervical spine muscles is effectively increase by a factor of 10, leading to chronic muscle tension, muscle fatigue and pain.

Thoracic hyperkhyphosis is associated with increased risk of several problems including increased risk of cardiovascular problems, pulmonary problems, increased risk of compression fracture of the spine and predictor of loss of physical function.  Hyperkyphotic individuals also have higher mortality rates[4].

Flattening of the curve in the lumbar spine has also been found to be positively associated with back pain.  Individuals with scoliosis have been found to have twice the incidence of back pain when compared to normal controls.  The evidence that demonstrates abnormal spinal alignment and balance is associated with pain, disability and poor health related quality of life. New research is constantly coming out demonstrating how spine alignment is link to health and functionality.

Is spine alignment correctable?

Chiropractic BioPhysics (CBP®) is chiropractic technique that focuses on restoring normal posture and spine alignment as its primary goals, while simultaneously improving pain and functional outcomes.  CBP focuses on correcting spine alignment through Mirror-Image® rehab methods involve exercises, spinal adjustments and mechanical traction.  Mirror-Image® means putting the spine in the exact opposite position as the spinal displacement.  In 1994 the first non-randomized trial was published using CBP® methods to restore cervical lordosis.  The trial demonstrated: 1) That sagittal curve alignment could be changed using mirror image traction and 2) spinal manipulative therapy on its own did not demonstrate changes is spinal curves[5].  More recently, Moustafa et al. have performed multiple RCTs showing improvement in cervical lordosis using mirror image traction as part of physiotherapeutic treatment programs.  These trials have shown superior long-term patient outcomes versus control groups who only received physiotherapy minus Mirror-Image® traction. This has demonstrated that spinal rehab methods that show improvements in spinal curve alignments have superior long-term reductions in pain levels versus ‘cookie-cutter’ rehab methods for pain relief[6].

Custom bracing has also been found effective in correcting large spine deformities such as scoliosis and thoracic hyperkyphosis.  Although some braces aim only to hold the spine in its current position to try to prevent it from worsening, some braces such as Scolibrace puts the spine in an overcorrected position to work to improve spine alignment.

Surgery is generally only considered when all conservative methods have failed.   Both spinal alignment and spinal balance is a major goal and consideration in spinal fusion.  Failing to improving sagittal and coronal alignment and balance increases the risk of poor outcomes post-surgery.

When dealing with any health problem once should begin by investigating what is causing the problem and what can be done to address cause instead of trying to only eliminate symptoms.  Even better, many problems may be predictable and preventable with early detection.  In 2015 the Scoliosis Research Society posted a position statement that the recommended adolescent teenagers be screened for scoliosis treatment as early detection leads to earlier treatments and better outcomes.  The same approach can be applied to all individuals as we live in an age of cell phones and tablets, being chronically sedentary and putting out bodies through repetitive micro traumas in daily life.  Like many chronic health conditions, the symptoms and side effects of poor posture and spinal alignment resultant from modern day living generally do not show until their later stages but when caught earlier they are much easier to correct with much better outcomes.

About the author:

Dr. Chris Gubbels is a Fort Collins Chiropractor located at Square ONE. To learn more Square ONE visit

  1. Pal, G.P. and H.H. Sherk, The vertical stability of the cervical spine. Spine (Phila Pa 1976), 1988. 13(5): p. 447-9.
  2. de Farias Neto, J.P., et al., Radiographic measurement of the cervical spine in patients with temporomandibular dysfunction. Arch Oral Biol, 2010. 55(9): p. 670-8.
  3. Seong, H.Y., et al., Prognostic Factor Analysis for Management of Chronic Neck Pain: Can We Predict the Severity of Neck Pain with Lateral Cervical Curvature? J Korean Neurosurg Soc, 2017. 60(4): p. 456-464.
  4. Kado, D.M., et al., Hyperkyphotic posture predicts mortality in older community-dwelling men and women: a prospective study. J Am Geriatr Soc, 2004. 52(10): p. 1662-7.
  5. Oakley, P.A., et al., Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications. J Can Chiropr Assoc, 2005. 49(4): p. 270-96.
  6. Moustafa, I.M., A.A. Diab, and D.E. Harrison, The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study. Eur J Phys Rehabil Med, 2017. 53(1): p. 57-71.