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Correcting Posture: Myth or Reality?
by: Anoop Balachandran

An anterior pelvic tilt will definitely lead to low back pain. A forward head posture or kyphotic posture will end in shoulder, neck, and upper arm pain. Always be upright when you sit and stand. And I am sure you have read and heard plenty more examples where posture is definitely linked to pain. It’s almost mandatory nowadays for personal trainers and strength coaches to perform a postural analysis as part of their initial assessments. And any deviations will be stretched and strengthened backed to the ‘ideal’ posture.

It’s quite obvious that the belief that certain postures will cause pain is so deep-rooted and wide spread in our society. But, surprising to say the least, there is little scientific evidence to show posture will cause pain. The simple fact that you see thousands of people around with bad posture with no pain and thousands more with ideal posture in a lot of pain just shows there is much more to pain than just posture. I think it’s high time that we take a closer look and see where we all went wrong and what we got right about posture and pain.

Posture Studies

One of the most common postural abnormalities is the forward head posture, and is often cited as a contributing factor in the pathology of subacromial impingement. The posture literature says that such a posture causes an increase in the thoracic kyphotic angle, causing the scapulae to elevate, protract, anteriorly tilt, and become rotated in a downward direction. All of these changes result in the loss of flexion, abduction range, impingement of supraspinatus tendon and the sub deltoid bursa against the acromion process. And hence the dire need to examine and fix posture. However, the evidence to support these ‘theories’ seems to be scant and contradictory.

Wright compared these distinct postural deviations claimed to be involved in impingement syndrome by comparing 60 symptomatic subjects (with pain) and 60 asymptomatic subjects [without pain] and concluded, “posture in asymptomatic and symptomatic people with subacromial impingement syndrome does not follow the set patterns referred extensively in medical, physiotherapy, and osteopathy textbooks and articles. The results suggest that posture may appear faulty, yet the individual maybe flexible and capable of large range of movements.” The author further goes on to point that postural assessment has a very limited role in the clinical decision making process in subjects with impingement syndrome [1].

These findings were supported by other studies, which reported no relationship to exist between forward head posture, forward slouch posture, and the curve of thoracic kyphosis in both symptomatic and asymptomatic people [2][3]. Similarly, no significant relationship was found between standing pelvic tilt and depth of lumbar lordosis in healthy folks [4]. Another study found clinical assessments of thoracic kyphosis and lumbar lordosis not to be in agreement with the radiological assessments [5]. Out of 427 people examined in another study, not even one showed a resting forwards head posture perfectly aligned with the ‘ideal’ posture postulated by Kendall in his seminal posture book [6].

Simply put, all the above studies show that the structural abnormalities claimed to be associated with certain postures and which seems to be the scientific rationale for correcting posture has very little science. More importantly, these studies hardly justify this raging interest seen among personal trainers and physical therapists in fixing posture to prevent pain.

The studies, which do seem to have seen structural differences between symptomatic and asymptomatic people, are confounded by the question of whether these changes contributed to the pathology or were just the consequence of the pathology or/and pain [7][8][9]. And this seems to be the basic question in all posture studies finding a correlation between pain and posture. Pain-evasive or antalgic postures, movements, and behaviors are often observed in response to pain.

A good question is, if posture has little to do with pain, then what about those work related musculoskeletal disorders (WRMD)? Quite a few studies have found an association between shoulder, neck, back disorders and posture [10][11]. As well, posture is considered to be an independent risk factor for musculoskeletal disorders among computer users [12].

Two things should to be considered when looking at studies about WRMD. First, by posture they mean the posture adopted by an individual to perform their specific work. This could range from simple standing or sitting to awkward postures, like sitting or lying with upper arm flexion, overhead work and so forth. Second, to complicate things further, these postures always involve some sort of low or high force, and repetitive motion for prolonged periods of time. This never means that the posture that involves flexion of your arm is ‘abnormal’ or sitting is ‘bad’. Instead it only means that any posture, even the ideal, if held for too long can cause disorder and pain.

If posture has at least a correlation to pain, then why not fix it? Strengthening exercises are often advised in an attempt to correct postural deviations. The assumptions being strengthening a lengthened weak muscle will result in the shortening and along with the stretching of the short antagonist result in the change in skeletal segment, and thereby posture.

Women with exaggerated pelvic and lumbar posture were analyzed to find the relationship between posture and strength. Radiographic analysis of the lumbar spine concluded that there was no relationship between lumbar lordosis and isometric strength of the trunk flexors, trunk extensors and hip flexors and extensors [13]. Walker showed no relationship to exist between pelvic angle, lumbar lordosis, and abdominal strength [4]. This was further validated by another study, which examined 90 healthy adults [14]. Youdas found the same, and went on to urge physical therapists to avoid prescribing therapeutic exercise programs of abdominal muscle strengthening in patients with low back pain based solely on assessment of standing posture [15]. That been said, a few studies do have found a relation between strength and posture. All in all, the studies shows that a strong muscle need not be tight, a lengthened muscle need not be weak, or just simply there is more to posture than just muscles.

An extensive review of studies looking at resistance training and posture alignment concludes by questioning the benefit of assigning strengthening exercises to change posture [16]. That is, exercises in the weight room may not help in fixing posture when activities at home or work are predisposing you to adopt a certain posture throughout the day. To make it even simpler, change your function, and form will follow; easier said than done, considering posture is profoundly influenced by genetics, culture, social, economic and psychological factors and is not just a conscious arrangement of “tight and weak” muscles to offset the force of gravity.

Pain Studies

Almost 450 years back, Descartes proposed the Dualistic Theory of mind and body being separate domains. Ever since, this Cartesian model of thinking has dictated the way we look at human nature, let alone pain. Descartes wrote, “the flame particle jumps from the fire, touches the toe, moves up the spinal cord until a little bell goes off in the brain and says, ‘ouch. It hurt’.” And most of our modern pain treatments have embraced this concept of a mesodermal origin of pain. Physical therapists strengthen and stretch the muscle to treat pain. Physicians are expected to diagnose and identify the damage causing pain. MRI and CT scans are almost always recommended to spot the cause of pain. Personal trainers blame weak and tight muscles as a cause of pain. It’s time that we spare some time from our busy lives and ask ourselves, if pain is a sensation produced by injury, inflammation, or tissue pathology:

Why are injuries ranging from moderate to severe not always accompanied by pain; sometimes no pain, or sometimes a lower pain which do not equate to the magnitude of injury? [17] Why do two thirds of the soldiers injured at the battlefields, and forty-percent of the people admitted to an emergency department feel no pain or pain of low intensity even after long delays [18][19] How often have you noticed yourself being covered with bruises yet being unaware of when and how it happened? Which therapeutic modality would help in relieving the pain experienced by amputees in their missing limb? And seventy- percent of the amputees report limb pain even years after the amputation [20]. How does the phenomena of secondary hyperalgesia explain tissues that hurt when you mechanically stress to be perfectly normal [21][22]? Why do individuals differ in their experience of pain? Why do some pains persist long after the injury is healed? How do you explain the pain that remains to a person, who had undergone an amputation, to get rid of the very same pain [23]? How do your thoughts, expectations, memories, beliefs, gender, and culture influence pain via the descending pathways [19]? Why is it difficult to treat chronic pain or pain which lasts for more than 3 months compared to acute pain? Why doe studies repeatedly show gross abnormalities, like disc bulges, spinal stenosis’, herniations, meniscus tears, and so on in people who have no history of pain? [24][25][26][27] Why does evidence based treatment for low back pain patients show decreased pain symptoms when the abnormalities on MRI show little change after the treatment? [28] What is the rationale for recommending ‘strengthening exercises’ for low back patients when the clinical changes in pain shows no relationship with the improvements seen in strength? [29].

If you have no clue, it’s simply because the cause of pain is multi factorial and complex, especially chronic pain. And our current treatment principles based on the biomechanical aspects of pain, while completely ignoring the neurophysiological and psychological aspects, have only made it more elusive. Even scientific studies intended to prove the ‘value’ of therapeutical intervention take great pains to eliminate the psychological dimensions and the so- called placebo effect. Though rapidly emerging, little consideration is given to the biopsychosocial model of pain which aptly describes that an understanding of pain must take into account not just the biological aspects, but also social and psychological factors. The International Association for the Study of Pain defines pain as an emotion. That is, pain is a perception rather than a sensation, and the experience of pain is fundamentally no different than why someone experiences a work of art as beautiful and engaging whereas another finds it as boring and mundane.

So why doesn’t nerve impingement or disc herniation or tissue trauma necessarily hurt or cause pain? The most likely explanation is that the compression occurred gradually over time, meaning that the brain safely concluded that there was no danger in the tissues (30). Unless and until the brain senses danger or threat, nothing can cause pain. A classic example of central nervous adaptation to pain is the pain, which lingers even after the limb is amputated. Constant inputs to the brain can alter the synaptic relations and permanently modify the neural circuits in the central nervous system (CNS), just like in long- term memory, and bring pain even when the tissue is missing (31,32). And even drugs rarely alleviate this kind of pain. The same parallel can be drawn in many chronic injuries that had more than enough time to heal (30).

Pain relies profoundly on context. For instance, subjects who placed their head in a sham stimulator experienced increased pain in line with the instructed intensity of stimulation even though there was no stimulation to begin with (33). This phenomenon called the nocebo effect is defined as harmful, injurious, unpleasant or undesirable reactions caused by the suggestion or belief that something is harmful (34,35). Nobody can argue against the wisdom of taking a few minutes from your workout to stretch and strengthen certain muscles to change posture. But the real concern is that by classifying postures and making people believe that certain postures (and movements) are bad and dangerous, we are instilling fear of these postures, raising the threat level in the brain, and in turn sensitizing the CNS to develop and maintain chronic pain (the fear-avoidance model) (36,37). In short, our casual conclusions about pain and posture are doing more harm than good.

I think we all can learn a lot from what Louis Gifford, one of the leading authors in the field of pain, has to say about pain and dysfunction, “It is important to note that we are full of dysfunctions whether we are not in pain or not. If we are in pain it is easy to find something wrong relevant to a precise tissue model but which may not be relevant at all to the patients state” (22).
Conclusion

All this enthusiasm is not meant to deny that there is a correlation between pain and certain postures, but that this association is neither sufficient nor conclusive to justify our efforts to choreograph people’s posture and movement. But what we do know for sure is that there is no ‘ideal’ posture, and any posture if maintained for too long will result in dysfunction, and maybe pain. The key is movement.

Now close your eyes, take a deep breath, slowly slump – and savor the freedom of movement.

Good luck

References

1. Lewis JS, Green A, & Wright c. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg. 2005 Jul-Aug;14(4):385-92.
2. Greenfield B, Catlin PA, Coats PW, Green E, McDonald JJ, North C.Posture in patients with shoulder overuse injuries and healthy individuals. J Orthop Sports Phys Ther. 1995 May;21(5):287-95.
3. Raine S, Twamey LT,. Head and shoulder posture variations in 160 asympomatic women and men. Arch. Phys Med Rehabil, 1997; 78:1215-23.
4. Walker ML, Rothstein JM, Finucane SD, Lamb RL. Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance. Phys Ther.1987; 67:512–516.
5. Tuzun C, Yorulmaz I, Cindas A, Vatan S. Low back pain and posture. Clin Rheumatol. 1999;18(4):308-12.
6. Grimmer, K. An investigation of poor cervical resting posture. : Aust J Physiother. 1997;43(1):7-1.
7. Lukasiewicz AC, McClure P, Michener L, Pratt N, Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. : J Orthop Sports Phys Ther. 1999 Oct;29(10):574-83; discussion 5
8. Braun BL. Postural differences between asymptomatic men and women and craniofacial pain patients. Arch Phys Med Rehabil. 1991 Aug;72(9):653-6.
9. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. : J Orthop Sports Phys Ther. 1999 Oct;29(10):574-83.
10. Aptel M, Aublet-Cuvelier A, Cnockaert JC. Work-related musculoskeletal disorders of the upper limb. Joint Bone Spine. 2002 Dec;69(6):546-55. Review.

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