Perfecting Posture Defeats the Purpose

It's both good news and bad news: perfect posture won't fix your pain.

One of the most common theories that patients and clients tell me about why they feel pain is their posture.

"I know my posture is horrible."

"I slouch all the time."

"A friend told me I should stand up straighter."

The messages we hear about posture from our childhood are powerful. But usually, they are not true -- at least when it comes to the evidence on overall health and pain.

The vast majority of the time, I look at these patients and would never think to critique their posture.

First, some background concepts:

There is such a thing as a habitual posture or, more specifically, one's position, that causes or contributes to someone's pain or problems. Physical therapists can look for a habit like this, then test to see if it is related to their client's pain, and -- if related -- teach techniques to change. This is not a nihilistic / nothing matters blog post.

Most notions of "Good Posture" are rooted in aesthetic, not biological or biomechanical or evidence-based choices.

Some of the cues about "Good posture" cause pain.

We are never still. It is normal and healthy to be moving, even in our sleep. Yes, we could all move more. But the idea that there is one perfect, unchanging (also not-quite-attainable) posture does not make sense. The idea that looking at someone in a static position is a good way to analyze their health is severely limited.

Perhaps most surprisingly, the published research on posture largely does not conclude that "poor posture" causes pain.

Today's post will focus on the published scientific research, and future posts will cover some of the other bullet points above.

Physiotherapists perpetuate the posture myth

"Despite a lack of strong evidence that any specific posture is linked to better health outcomes", most physical therapists and physiotherapists do believe there is one optimal posture.

"While postural re-education may play a role in the management of spinal pain for some patients, awareness of such widespread and stereotypical beliefs regarding optimal posture may be useful in clinical assessment and management."

In other words, the profession of physical therapy -- at least in this study of Greek physiotherapists -- has largely bought into the concept of "optimal posture" and may be perpetuating one or more false ideals, despite the lack of evidence. https://pubmed.ncbi.nlm.nih.go...

Your Low Back Curve is Unrelated to Pain

A systematic review from 2014, "Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis" shows a few interesting trends:

First, it shows NO difference in lumbar curve ("lordosis angle") between people with and without low back pain.

Relatedly, it also showed no difference in low back pain and the tilt of your pelvis -- anterior or posterior tilt.

Anecdotally I find that many of my patients benefit from changing these habitual positions, but 1. I suggest change of position when testing indicates that will help. And 2. it is possible that the benefit comes from the "novelty" of not being overly stiff in their low backs. In fact...

The main differences found by this review between healthy controls and people with low back pain were as follows. People with low back pain have reduced flexibility (range of motion) in their low back, and they have reduced "proprioception", or ability to perceive position and movement.

Does holding "perfect" posture improve range of motion or proprioception? No. Only movement practice can increase ability to move or perception of movement.

(free article:) https://pubmed.ncbi.nlm.nih.go...

Posture is less relevant than movement itself.

Finally, a summary article from 2021. https://pubmed.ncbi.nlm.nih.go...

These authors have spent way more time than me diving into the details of research studies. Here is what they have concluded:

"The mounting yet established research evidence suggesting posture deserves less focus when managing pain, and the importance of understanding when to provide specific postural advice. It argues that, in general, posture is less relevant than movement itself, and creating change in patients' behaviour and beliefs requires understanding, physical examination, clear communication and not necessarily deeming the role of posture as irrelevant."

Conclusion

There are many more studies demonstrating that the links between posture and pain are tenuous.

Aaron Kubal is an evidence-based practitioner who debunks common tropes about musculoskeletal issues has made some great Tik Toks and Reels. Here's one. Here's another.

Aaron summarizes his thoughts with "There are no inherently bad postures, just postures your body is not yet capable of sustaining without discomfort".

This is the view on posture that is most consistent with reality. Not everyone has pain when slouching -- even for hours each day. Olympic athletes put their bodies under immense load in non-"optimal" postures. The indigenous people I met in Colombia in 2019 who walked three hours barefoot down from the Sierra Nevada didn't look bothered about their posture as they sat on a rock by the beach, spines rounded.

Constantly aiming for perfection from stiff and overactive back muscles also simply doesn't feel good.

I hope this gives you more ease about your posture, and, as always, if you need help getting out of pain, outsource the responsibility to us by booking a session.

More thoughts in this quick video: https://youtube.com/shorts/cQ4...

Published Jan 16, 2024

Categories: Anatomy and Alignment, Habits, Physical Therapy