PT on the Net Research

Sway Back


Question:

I have a client who recently discovered she has a condition known as "sway back." Her massage therapist described the condition as excessive, unnatural curvature of the low back. I have attempted to research this condition and have yet to find any credible sources to provide information. I'm not sure if I should incorporate more stretching, stabilization and balance exercises, strength or something else that will specifically help her feel better. She has seen countless doctors, chiropractors and physical therapists over the past six years, and nothing seems to be able to alleviate her low back pain. Can you give me any information on this apparently rare condition of "sway back?"

Answer:

You should be commended for your compassion and concern for your client. However, I would encourage all fitness professional to stay away from the specific goal of helping a client in pain to “feel better.” Those words can immediately cloud the boundaries of our scope of practice, even when that is not the intent. Normally, your first course of action would be to refer your client to a qualified health professional for an evaluation and treatment. But it sounds like she has “been there and done that.”

That being the case, each of us as fitness professionals must first design our musculoskeletal exercise programs around a thorough assessment. Second, we must avoid any exercises that might exacerbate or reproduce pain or symptoms. If we do both of these steps effectively, there is a very good chance your client will feel better because she is functioning better and not because you gave her something (i.e., an exercise) to make her feel better.

The sway back pose you speak of is actually quite common. It can be accurately assessed with the assistance of a plumb line. This posture reflects a deviation in the sagittal plane. When viewing your client from the side, the hip joint axis is displaced anteriorly of the plumb line. Therefore, the hip is in an extended position. With this, the individual will usually have poorly developed gluteals and overly developed hamstrings that compensate for the gluteals.

Additionally, the pelvis will be in a posterior tilt with an elongated and weak iliopsoas. The anterior movement of the pelvis will also cause a postural lengthening of the external obliques, which can lead to weakness of this muscle group as well.

The actual term “sway back” comes from the movement of the thoracic spine posteriorly to counter the shift of the center of gravity forward that results from the anterior displacement of the pelvis. In other words, to remain upright, if we have a “zig”, then we must have a “zag.” This creates a longer than normal curve at the thoraco-lumbar junction, which is sometimes mistaken for an increased lordosis (which your client’s massage therapist may have done). This leaves the thoracic extensors in a posturally lengthened position and usually leads to weakness of this muscle group.

Exercises that address the above mentioned muscle groups from a muscle balance perspective could have a very positive effect on your client. Your client may have many altered movement patterns resulting from her structural alignment issues and pain avoidance. Consider using single plane and simple exercises initially until your client demonstrates the ability to perform them without compensation. Stay away from stability balls and other unstable devices until she is able to maintain the appropriate alignment on stable surfaces during exercises.

Two excellent texts on the subject of postural issues are:

  1. Muscle Testing and Function by Florence Kendall et.al.
  2. Diagnosis and Treatment of Movement Impairment Syndromes by Shirley Sahrmann