Stand up to gravity this year.

Better posture for a better world in 2024.

Sit up straight.

Stand up straight!

Keep your head up and shoulders back.

It may be that every human being since the dawn of civilization has heard at least one of these commands spoken to them at some point in their lifetime. Depending upon the enlightenment of the era and the temperament of the advisor, perhaps there was a small smack involved. Maybe this held true with the Neanderthals as well.

As bipedal primates we face an exhausting, Sisyphean, daily struggle to resist the gravitational pull exerted by 6.585 billion trillion tons of Earth. That’s heroic. And it shows. It pulls us downwards into stooped postures. We develop rounded thoracic spines, and eventually may be labeled with an opaque medical term like kyphosis.

What is kyphosis? How does it develop, and to what extent does a lifetime of poor posture contribute? Can we prevent it? Treat and improve it? And most importantly: will standing up straight, tall, and powerful in a Wonder Woman pose actually make us become more powerful ourselves?

What is kyphosis?

Quite simply stated, this refers to an abnormally curved upper back that leads to a more rounded or hunched posture than normal. Whether we meet any technical or radiographic criteria for being labeled as kyphotic is less important for the purposes of this post than recognizing we all have a tendency to stoop forward. Gravity and axial loading. Up to 40% of older people have clinicaly significant kyphosis, and almost all of us have some degree of postural imperfection.

How does kyphosis develop?

One common cause of kyphosis is poor posture, especially in the era of increased sedentary activities and prolonged periods of sitting.

Other contributors include degenerative conditions such as osteoporosis, where weakened bones can lead to vertebral compression fractures. Degenerative disc disease occurs naturally as the spinal discs start to shrink and break down. Deconditioning can lead to weak back muscles that make it harder to stand up straight. Additionally, congenital factors, spinal injuries, and certain neuromuscular and collagenous disorders may also contribute to the development of kyphosis.

And while vertebrae, discs, muscles, tendons, and ligaments all play prime roles in our posture, we should also consider that confidence and mood can absolutely affect how we physically carry ourselves.

What does kyphosis look like?

The figures in these anatomic drawings are not of equal weight as far as I can estimate, so that’s not quite fair. The medically mean term “dowager’s hump” is on display. But for a public domain image we get the idea. I’ll point out that a stooped posture can also result in tight hamstrings, a ribcage that bows outwards, and other upstream/downstream musculoskeletal compensatory mechanisms that can contribute to chronic pain.

What are some possible symptoms?

A hunched or rounded back might hurt or feel stiff. Other possible symptoms can include neck or hip pain, trouble breathing or swallowing, acid reflux, and eventually trouble doing activities of daily living such as walking, getting up from a chair, dressing, and bathing.

Can we prevent it?

To a significant degree, yes. We cannot change the natural degeneration that happens to us all, but staying active physically can help. Focusing on good posture requires a commitment to continual awareness and self-correction. As I write this I am stooped over! I am sitting up straighter now, with shoulders back, chin up a bit, both feet on the floor. Maybe I’ll move over to the standing desk I have and practice engaging my core muscles, tightening gluteal muscles, pinching shoulder blades together. But by the time I’m done writing this sentence I will have collapsed again. Practice, patience, and persistence.

Are there treatments? Can we improve kyphotic posture?

Yes, and yes. Exercise as an initial treatment is recommended by most experts and backed by the evidence. Initial exercise under the guidance of a physical therapist when possible is even better.

Exercise should focus on postural alignment, flexibility, and core strengthening. Ideally these should be continued on a daily basis. One more thing to add to the exhausting list! From the clinical reference UpToDate that I subscribe to, here are two simple and basic techniques to get us started:

• Have the patient stand up with their back and feet against the wall to obtain as upright a posture as possible, with their eye gaze straight forward. Once positioned correctly, teach them to engage the diaphragm for deep breathing to make them aware of their core abdominal muscles. Next, instruct them to take five deep breaths, paying attention to their posture so they can continue to practice good posture throughout the day.

  Secondly, instruct the patient to raise their arms above their head and then into a cactus position, extending their chest upwards and forwards, and repeat the breathing exercises.

• Have the patient transition to an “all fours” posture on the floor, and instruct them to practice the cat-cow positions (alternating spinal rounding and extension). With the cow, take a deep breath, and with the cat, exhale. Repeat about five times.”

I’m not sure about “transitioning the patient to all fours on the floor” during their visit. That might feel awkward for both of us. Better to send out a Substack newsletter? There are a lot of physical therapists who post helpful posture related videos on sites like YouTube.

But does exercise really help stooped posture/kyphosis?

• In the most comprehensive review and meta-analysis of studies involving older adults with kyphosis of at least 40 degrees, among 24 included studies, exercise or physical therapy improved kyphosis with moderate-certainty evidence and increased back extensor muscle strength and endurance with low-certainty evidence.

• At least seven randomized exercise trials demonstrate that exercise interventions in older adults may improve kyphosis by 3 to nearly 7 degrees, as determined by radiographic Cobb angle measurement or dual-energy x-ray absorptiometry (DXA) imaging.

There is limited data showing benefit of other treatment options, including spinal braces, postural taping, pharmacologic therapies, and surgery.

Does our posture impact our self-image and success in life?

I really like this TED talk by social psychologist Amy Cuddy entitled Your body language may shape who you are. It has been viewed 70 million times, and is the second most popular TED talk of all time. Unfortunately she came under fire for some of the studies and evidence she presented. Some researchers noted that her studies were small and lacked the statistical power to make firm conclusions. Others were not able to consistently replicate her study results. Nonetheless, she does present a convincing argument that nonverbal expressions of power are conveyed by factors like our posture. It is better to expand our stance than shrink it. We should aim to stretch our bodies larger rather than collapse them smaller. And Wonder Woman was power posing before that was even a thing politicians started doing after Amy Cuddy’s talk.

Power posing is a self-improvement technique in which people stand in a posture that they associate with being powerful. The goal of this technique is to potentially feel more confident and assertive. Whether power posing works or not is controversial, but I kind of like the idea, if only to improve our postures for health reasons.

Along those lines, I wrote a post a while back about shadowboxing. I have done no clinical trials to support my belief that it's kind of a perfect exercise, stress reliever, and ego boost, so I’ll just say it works for me, and the late great Muhammad Ali.

Gravity always wins

I will concede that we all struggle to remain conscious of our standing and sitting postures. I’m guessing your posture could be improved right now as you are reading this. Mine can. Again.

But no need to just listen to me. What does Radiohead say about posture? I’d like to welcome all the new subscribers from the UK who signed up this week, presumably from a recommendation from fellow Substack writer and Philadelphian

Catherine Price

. If you haven’t signed up for her newsletter about the power of fun and how to have a healthier relationship with your cell phone, do so now! So to establish my credibility with new English readers, I will quote the following line from Radiohead’s song Fake Plastic Trees:

He used to do surgery
For girls in the eighties
But gravity always wins
And it wears him out

I saw Radiohead play June 23rd at the Theater of the Living Arts in Philly. 1993. It was only their second performance in the United States. Ever. Pablo Honey tour. Small intimate venue. Creep. Hopefully this has established your trust in me as a physician writer. Welcome!

Gravity does always win, so take heart if your kyphotic posture cannot be completely fixed. Mine can’t either, but I try, and it helps.

Stand up to gravity this year

Will a resolution to work on awareness and execution of better posture make much of a difference in the new world of 2024? With all the much more existential problems we face probably not. But in the microcosm of our own lived experiences it should help with aching, pain, declining physical abilities, and overall health and wellbeing. Better posture might just lend us some power in terms of how we present ourselves to the world and others. Body language leads to automatic judgements from other people observing us. Their judgements and reflexive reads of us affect actions, opportunities, and outcomes. Posture also affects how we conceive of ourselves.

So why not try to stand just a bit taller, if only to fulfill the Herculean and ultimately Sisyphean challenge of standing up to those 6.585 billion trillion tons of Earth.

It’s what we humans do better than other animals.

That, and cooking.

Cheers, and happy New Year!