A lot of people in the health and rehabilitation communities have long stressed the importance of "good" posture in the prevention of pain and injury. I remember being taught of it's importance throughout university and learning techniques and exercises that were supposed to "correct" poor posture. I'll admit that I used to subscribe to these ideas and on the surface it does seem to make sense and could be a plausible theory to explain people's cause of pain.
But as I've learnt more I realised that simply believing an idea based on intuition is not the best way to test your theories. That is what we have science for, so we can put these theories to the test to see if they hold water.
So to determine if posture and indeed "poor" posture is a good indicator for the likelihood of whether someone will experience pain we need to answer a few questions using available data. Only then will we be able to make an informed decision.
Firstly, what is "good" and "bad" posture?
There is some grey area around these definitions which is also why I'm not a huge fan of describing them in terms of good versus bad. When most people say "poor posture", they tend to be describing certain characteristics such as rounded shoulders, slouched back, anterior (forward) head position, an uneven pelvis and leg length differences to name a few. The proponents of this terminology contend that being in these positions will lead to injury and/or pain.
In contrast, the term "good posture" is usually meant to describe someone with a more neutral (straight) spine, retracted shoulders, centred head position, level pelvis and equal leg lengths. These characteristics are said to reduce injury and are "optimal".
So lets dissect one of those characteristics a bit further, anterior head position (meaning that your head sits forward on your body) to see how well it correlates with pain. If your head is sitting more forward on your body then the muscles and joints in your neck may have to work harder and be put under more stress right? Well maybe it's not that simple. Let's look at what the evidence says.
A study looking at Australian adolescents found no association between those who had an anterior head position and the likelihood they would have neck pain (1). This corresponds with my own personal experience as an adolescent where throughout primary school I would spend the 30 minute car ride to and from school everyday reading books with a "bad posture". I would sit with the book laid on my lap and my head pointed down with a large amount of anterior head posture and would not look up until we had made it to school. Did I suffer any neck pain or injuries? Nope. None whatsoever.
Now you might rebut this and argue that the findings from the previously mentioned study and my own personal anecdote were due to the fact that this involved younger people and they may not be as susceptible to injury as adults are? Fair question to ask. But again that doesn't seem to be the case. Another study looking at older adults this time showed that there is no significant association between an anterior head position (from a reduction in cervical spine curvature) and the presence of pain (2). So if we can't draw a strong link between head position and neck pain, we sure as hell can't assert that "if you spend too much time looking down at your phone, you will get neck pain".
So what about people who are in pain? What do their postures look like? Could it be that people in pain adopt different postures than those that are pain free?
A systematic review of 43 studies looking at the bio-mechanical and postural differences between people with and without back pain concluded several interesting findings. They found that people with back pain had "no difference in their lordosis angle" (the amount of arch in their low back) when compared with those who had no pain (3). Their findings also showed no correlation between pelvic tilt and back pain (3), which is very interesting because I've seen many "opinions" around that swear excessive pelvic tilt will cause back pain.
This same systematic review, along with showing no correlation to posture and pain, did show some interesting findings regarding movement and the presence of pain however. Their conclusion was "people with LBP (low back pain) have reduced lumbar ROM (range of motion), move more slowly and have reduced proprioception compared with people without low back pain" (3). Proprioception is the perception or awareness of the position and movement of the body.
The presence of pain causes people to alter their normal movements and they become afraid to move, we call this FEAR AVOIDANCE. It may be useful in the immediate short term after experiencing back pain but if allowed to linger fear avoidance is linked to developing chronic pain (4). That is why it is always important to receive advice from an experienced clinician that can assess and reassure you that movement is good for you and indeed necessary for recovery.
Can certain positions lead to pain then?
Most definitely. But I would contend that this arises more as a result of being in one position for long periods and not moving through various ranges of motion. I'm sure everyone has experienced some discomfort or pain from sitting in an uncomfortable seat for too long or been a bit stiff after getting up off the couch after a 3 hour movie?
Bodies are built to move and staying in any one position for too long will cause some discomfort. Test this theory out if you don't believe me. Try sitting in the supposed "perfect" posture at your desk for several hours without moving and tell me how you feel. I'll give you a hint. Stiff, restless, and uncomfortable.
But why do we feel these unpleasant sensations? The body is telling us we need to move. We have these cool alarms in our bodies called Acid Sensing Ion Channel Sensors and their job is to activate when acid levels start to build up too much in our tissues (5). So if this acid builds up too much these sensors alert you and you may feel some pain or discomfort. And what reduces the acid levels in the body? Movement! The contraction and relaxation of muscles that occurs when we move helps to circulate this acid out of the tissues and around the body to be broken down.
This leads me to my final question and it involves specific exercise training targeted at improving poor posture. Are we actually able to correct "poor" posture long term?
Many people argue that poor posture is caused by a combination of overly tight muscles, coupled with opposing weak muscles that are unable to compete with the tight muscles. Frequently accused muscles include tight pectoralis muscles, that may pull your shoulders forward, coupled with weak rhomboids or trapezius muscles that act to retract your scapulas, thus holding the shoulders back.
So a standard prescription to help this combination would include scapula retraction exercises to strengthen the rhomboid/trapezius and stretching for the pectoralis muscles. Does it work? Luckily we have research looking at exactly this! The findings from a study out of Victoria University concluded that "it is inadvisable to strongly promote strengthening exercises to correct postural misalignments" (6). If there isn't clear evidence that these interventions do what we hypothesise they do then I would assume that further investigation would be necessary.
In closing, I see why many are quick to jump on the posture band wagon and blame it for the cause of many issues, but sometimes we need to take a step back and reassess, look at what the evidence says, then make our judgement call accordingly.
Given the current evidence it does not appear that we can use a blanket statement and say that certain postures are responsible for pain. Also adopting "poor" postures does not seem to predispose you to experiencing pain more than the next person with "good" posture. There are many factors that go into pain and it is a complex topic that requires ongoing research and study. People are individuals and if you are experiencing pain it is important to work with a clinician that understands this. That way you can work together in order to find what will work for you specifically and to navigate through the questionable advice that is out there.
If you would like any more information or are experiencing pain and would like some advice, you can book an appointment at Forward Osteo online or call the clinic on 03 5215 1788.
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Aidan Mill is the owner and principal osteopath at Forward Osteo
Osteopath Geelong West
References:
1. Richards, K. V., Beales, D. J., Smith, A. J., O'Sullivan, P. B., & Straker, L. M. (2016, October). Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27174256
2. Grob, D., Frauenfelder, H., & Mannion, A. F. (2007, May). The association between cervical spine curvature and neck pain. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2213543/
3. Laird, R. A., Gilbert, J., Kent, P., & Keating, J. L. (2014, July 10). Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25012528
4. Gatchel, R. J., Neblett, R., Kishino, N., & Ray, C. T. (2016, February). Fear-Avoidance Beliefs and Chronic Pain. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26828236
5. Boscardin, E., Alijevic, O., Hummler, E., Frateschi, S., & Kellenberger, S. (2016, August 10). BPS Publications. Retrieved from https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bph.13533
6. Hrysomallis, C., & Goodman, C. (2001, August). A review of resistance exercise and posture realignment. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11710670
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