Does Posture Matter? Episode 1: The Postural Menace

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There has been a recent buzz online about posture, and particularly about its importance in clinical settings for assessing, treating, and preventing pain. A growing number of physical rehabilitation specialists (physical therapists, chiropractors, etc.) are pointing to the fact that the current body of research does not definitively demonstrate a strong link between static posture and pain. Articles and debates are popping up on physical therapy and chiropractic blogs and websites suggesting that attention to static posture and treatments or preventative measures related to static posture do not have any place in therapy/rehabilitation practice [1] [2] [3]. However, as is often the case with the internet, conversations and articles over a parallel topic with a diametrically opposite viewpoint are making their rounds on everyone's Facebook feed at the same time. One in particular that has garnered its share of attention recently is the topic of "text neck" [4] [5] [6]. Given that most citizens of the Western world have a smartphone surgically attached to their hands by now, this is an eye-catching and relevant topic. As is also typical of mainstream articles on health and medicine that are desperately clamoring for your clicks, the writing is sensationalized and full of scary words and phrases like "epidemic," "permanent damage," and "wreck your spine." The text neck crusaders are out to remind the public that poor posture can cause pain and affect your health, and that it deserves attention and correction.


So, who's right? Does posture deserve your and your physical therapist's attention? Does static posture put you at risk for developing pain or dysfunction? If you have poor posture but are pain free, is there any reason to put effort into improving your posture? Is your spine going to explode if you look down at your cell phone for too long? Are the robots taking over?

Graciously, the internet's mystical and dichotomous ways have presented us with a perfect opportunity to challenge and question conventional wisdom regarding posture and pain, to ask questions that likely are not asked enough, and to ensure that we are not letting tradition supersede knowledge and thoughtfulness.

(Note: Throughout this post and further posts on this topic I will be using the term "posture" to refer just to static posture, and will specify dynamic and/or loaded posture when that distinction is needed.)


My Point Is...
Ultimately, yes, posture does matter. We can all agree that the articles on "text neck" are over the top, and that some of their tactics for gaining readership have a tinge of blatant sensationalism. However, these articles and others like them are not without their merits. No, your spine will not explode from looking down at your phone for too long to get your Twitter fix; however, day-to-day posture and accumulation of time in poor positions is something that deserves your attention and the attention of health professionals alike. It may not be the most imminent threat facing our society today, but it behooves everyone—from high level athletes to desk jockeys—to understand the how and the why of posture's effects on pain, function, and performance.

In this post and the rest in this series, I will address the major aspects of this ongoing discussion on posture and its significance in preventing pain and optimizing function and performance.


The Research
A few minutes of Googling will reveal that, to date, there really isn't much out there in the way of scientifically conducted research that definitively shows a link (causative or correlative) between posture and pain. But, on the other hand, there really isn't much out there in the way of scientifically conducted research that definitively shows there isn't a link between posture and pain. Most of what we have is research concluding that "the results are inconsistent, and therefore don't show a strong correlation." So those who argue that posture is largely irrelevant in treating pain are absolutely correct about the current standings of the body of research.

But honestly, it should not be surprising that research has yet to definitively demonstrate a link between posture and pain. Research conducted on this issue is mostly limited to cross-sectional studies, retrospective studies, and prospective studies with small groups of subjects; and, any study that sets out to examine something as variable (and often ill-defined) as posture and as mystifying as pain is bound to encounter limitations.

In cross-sectional studies, researchers take a group of people with back/neck pain and a group of people without pain and, using radiography, a flexicurve, and/or some other postural assessment tools, examine the positions/alignment of their joints (particularly in the spine) to look for patterns in posture that can be linked to the pained or pain free group. The greatest limitation of this method is that it only looks at a snapshot of the individual's posture and pain. The complexity of posture cannot accurately be captured in a snapshot. Posture is not a position at a given moment, but a series of ongoing positional patterns (it could be considered an "average") for sitting, standing, lying, etc. In addition, being aware that they are part of a study on posture, it is entirely possible (if not likely) that subjects' body positions during their examination for the study will not be true to their day-to-day posture.

In retrospective studies, groups of individuals with back/neck pain or a history of back/neck pain are asked to report, retrospectively, on their posture. These studies may also been done in combination with a cross-sectional study. The limitations on this one are rather obvious: most people can't remember what they ate for breakfast yesterday, much less how their posture has been since middle school. Additionally, much of the population is largely unaware of their posture (lacking proprioception) and general movement patterns. This does not lend itself to detailed and accurate self-reporting.

In prospective studies, researchers focus on a group (or groups) of people with a common hypothetical risk factor—in this case, poor posture—and look for the development of conditions, such as neck or back pain, over time. Of the three, this research method is the most likely to produce consistent and revealing results. However, it still has a few considerable limitations. Because prospective studies require researchers to follow subjects for long periods of time, it is generally the most costly and demanding type of study. In order to get substantial and revealing outcomes, any study on posture will require a large population to be examined; however, the cost and labor demand of prospective studies will present a limit to the number of subjects that can be followed. For this reason, long-term follow up with subjects of the study may be conducted via a mail or phone questionnaire and rely upon self-reporting rather than the more costly and impractical (but more accurate) option of assessment by a medical professional. Therefore, even in prospective studies, researchers end up with only an initial snapshot of the subject's posture; they do not collect measurements of long-term trends or changes in one's posture, and therefore face similar limitations as in a cross-sectional study. In addition, the primary strength of a prospective study—that it examines subjects over a long period of time—also presents a challenge in this type of research. Posture and posture-related habits can (and often will) change over time, and the challenge of tracking the introduction or cessation of additional risk-factors in each patient over an extended period of time mars the clarity of any results from such a study.

In addition, all of these methods fall short in that they focus almost exclusively on pain (specifically, back/neck pain). While pain is incredibly deserving of researchers' and practitioners' attention—it is our body's primary way of saying, "hey, something's not right here!"—it does not tell the whole story, and is a phenomena that follows rather inexplicable patterns. A considerable population (I've seen estimates between about 20-60%) of individuals with considerable tissue damage (think torn or frayed ligaments, bulging and degenerating spinal disks, damaged cartilaginous tissues, etc.) walk around with no pain at all [7] [8] [9]. And meanwhile, people with no signs of tissue or nerve damage find themselves in constant and severe pain [10] [11]. When health practitioners and researchers focus exclusively on pain, they ignore the relevance and importance of other factors affecting function/dysfunction, and they do themselves and their patients a disservice.

Ultimately, posture is a difficult beast to pin down and track. Life does not occur in a laboratory, and therefore something like posture which is, by nature, very dependent on and related to a massive diversity in lifestyle and individual physiology, will always challenge our research methods. Even the researchers conducting these studies and health professionals arguing against the use of posture-based practices in clinical settings punctuate their claims with qualifying terms like "probably," "inconclusive," "likely," "possibly," and "unclear," and most online articles denouncing posture-based treatment outright admit: most of these studies are poor quality and the evidence is not entirely clear one way or the other.

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It should also be noted that none of my caveats about the condition of current research really prove or suggest that posture does correlate in any way to pain or dysfunction. As with most contentious scientific matters, there is research that supports both hypotheses; but the research indicating correlations between posture and pain all face the same short-comings and challenges as the research proposing the opposite. Looking only at the research, we end up with something of a moot point.

However, some argue that because the body of research more strongly leans (by volume) to the side of "no considerable correlation," that physical therapists, trainers, and other health professionals should forego posture-related corrections and diagnoses from their practice. In other words, because our current body of research cannot not provide evidence that poor posture does cause pain, it must not cause pain. This, to me, looks like a classic case of argumentum ad ignorantiam (shout out liberal arts education). It is an appeal to ignorance.

To further support their argument, some contend that continuing to enforce the importance of "good" posture in the medical field is actually a disservice to patients, as it runs the risk of causing a nocebo effect. While this is a potential risk, I ultimately believe that the potential benefits of postural awareness and practicing good posture far outweigh the potential risks. It is the duty of any health practitioner to be familiar with up-to-date research and to understand the medical field's official (or unofficial) stance on an issue. However, I believe that it is also the duty of any health practitioner, and of any free-thinking human being with a fully functioning brain and internet access, to examine the research within a more holistic context and with a hefty dose of common sense.


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In the next post of this series, we will take a look at how and why posture can affect pain, function, and performance.

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Stay swole. 

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Photo Credits:
1 Thinker, Texter, Reader via photopin (license)^↩
2 Spine Cervical and Upper Thoracics via photopin (license)^↩