An in depth review of the postural debate
Recently I published an article on the Personal Training Development Center presenting my views based on the evidence on why I don’t feel that trainers should focus on postural assessments or interventions to ‘fix’ posture. Overall it was well received despite being such a hot topic. Within twenty four hours thePTDC posted a rebuttal paper to my paper. I received several messages from colleagues on the topic and two of them, Lars Avemarie and Jason Silvernail put their thoughts together and came up with a rebuttal to the rebuttal if you will. The first part is from Lars and the second part is from Jason. Throughout all of this it is important to remember to only look at the evidence. The evidence presented is simply that, evidence. It reflects the authors well thought out interpretations based off of dozens of studies. Personal attacks because evidence does not support a certain viewpoint should not be in the conversation. I look forward to continued debate on the topic as it will only help both sides improve as professionals. Let’s continue this discussion fairly and impartially using only the facts presented.
When I read Ellen’s rebuttal I felt that in my opinion she was not giving a fair presentation of the whole body of evidence, and I felt compelled to write this.
I work full time as a certified personal trainer in Sweden, my focus is on using evidence-based methods to fulfill my client’s goals. As a trainer I work with all clients from weekend warriors to exercise enthusiasts of all ages.
So here is the rebuttal of the rebuttal. So now I’m going to go point by point through Ellen’s rebuttal, of Justin Kompf “Is Posture Important?” article. For easy reading Ellen’s statements are in bold.
“for example (and this is something like what I say multiple times a day) you have a slightly rounded back, but by doing some exercises and avoiding slouching for long periods, you can improve it”
Some studies (1, 2) suggest that you can’t change posture with exercise.
The O’Sullivan study that you are citing with the title “The relationship between posture and back muscle endurance in industrial workers with flexion-related low back pain” from 2006 are actually stating it as a correlation, and that is something very different that a causation, here is what they say.
“Correlations between increased time spent sitting, physical inactivity and poorer back muscle endurance were also identified. There were no significant differences found between the groups for the standing and lifting posture measures. These preliminary results support that a relationship may exist between flexed spinal postures, reduced back muscle endurance, physical inactivity and LBP in subjects with a history of flexion injury and pain.”
We also always have to rememeber, “correlation does not imply causation”.
“but from my clinical experience there is a strong correlation between poor posture and back pain”
Yes, you can have poor posture and back pain, but again that does not mean that the poor posture caused the pain, and your clinical experience, is not proof of anything, personal experience has a very low level of validity (3, 4), and again “correlation does not imply causation”.
The view that poor posture can cause pain is a very simplistic view of what pain is.
This goes against the consensus. These structural or biomechanics explanations for pain and chronic pain are currently unsupported by the full body of evidence, as the causal factor of pain, and in the last 10-20 years of pain research have dismissed them.
There is a large consensus on the biopsychosocial model of pain (5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18). The biopsychosocial model (BPS) conceptualizes that biological, psychological (thoughts, emotions, and behaviors), and social factors, all play a significant role pain and the pain experience.
Now I will highlight some of the evidence, here are some of the statements made in the reviews/research.
from citation no 17.
“Pain is not simply the end product of a linear sensory transmission system; it is a dynamic process that involves continuous interactions among complex ascending and descending systems. The neuromatrix theory guides us away from the Cartesian concept of pain as a sensation produced by injury, inflammation, or other tissue pathology and toward the concept of pain as a multidimensional experience produced by multiple influences. These influences range from the existing synaptic architecture of the neuromatrix—which is determined by genetic and sensory factors—to influences from within the body and from other areas in the brain”
“Protruding discs, arthritis of vertebral joints, tumors, and fractures are known to cause low back pain. However, about 60-70% of patients who suffer severe low back pain show no evidence of disc disease, arthritis, or any other symptoms that can be considered the cause of the pain”
from citation no 15
We tend to endorse the complexity of the brain and its fundamental role in what we experience. Unless, of course, we are talking about pain
The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain , neck pain  and knee osteoarthritis ).
from citation no 16.
Clinicians should not utilize patient education and counseling strategies that either directly or indirectly increase the perceived threat or fear associated with low back pain, such as education and counseling strategies that (1) promote extended bed-rest or (2) provide in-depth, pathoanatomical explanations for the specific cause of the patient’s low back pain.
In addition to medical conditions, clinicians should be aware of psychological and social factors that may be contributing to a patient’s persistent pain and disability, or that may contribute to the transition from an acute condition to a chronic, disabling condition. Researchers have shown that psychosocial factors are an important prognostic indicator of prolonged disability.
You also stated this:
“Poor sitting posture has been consistently shown to be a strong predictor of low back pain .
Moreover when you say that there are studies which have found no correlation – while this is true, more recent studies have found that back pain and posture can be subgrouped, so there is a subgroup who hold themselves actively into extension who have pain, and a subgroup who are in excessive flexion with pain (but if you look at the group as a whole, without subgrouping, it appears like there is no difference to people without pain)”
In this part you are introducing a new variable “sitting”, now sitting is something other than posture, and from the one study you cited, we can only state that poor sitting posture can be a strong predictor of low back pain, not posture itself.
Now sitting CAN put stress on the low back as shoved by the classic Nachemsons (19) study and the newer reproduction (20), but that does not equal back pain.
“You mention pelvic tilts – I find that normally they do affect pain and performance, but everyone is different”
Your experience is again not proof of anything, and almost anything can “affect” pain, and there is no correlation between pelvic asymmetry and or pelvic tilt (21).
“Furthermore a correlation has been shown between asymmetric posture and low back pain”
Again that is a correlation and “correlation does not imply causation”, and this again goes against the current consensus.
“One thing that I often do is get a patient out of a bad posture and into better posture, and demonstrate to them that their pain goes away with that”
Poor posture is not a causal factor of pain (22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35).
But there are some studies that do show a correlation between both pain and posture (36, 37, 38).
If we go deeper down the rabbit hole pain is influenced by sight and colors (39, 40), pain is less painful when we are convinced that we are safe (41), and “nociception” is not necessary for pain (42)and influenced by sleep (43), and even to think of movements that produce pain, can cause pain and swelling (44).
“I also think that neuromuscular control is more important than standing posture, and that is not something that (as far as I’m aware) personal trainers are qualified to assess/should be assessing (articles [5, 6, 7] have some info on this)”
Some of your references 5, 6, 7 have been been refuted (45, 46, 47, 48, 49)
As the last note, I have talked with Nick Tumminello, and he mentioned that the notion of subgroups:
“Many clinicians have challenged the validity of these research results (you just learned about) as they feel that the lack of associations with the factors described above is at odds with their clinical experience of managing patients with low back pain.
The School of Health Sciences published a 2008 paper (50) to address these concerns, which stated, “A common explanation for this discrepancy is the perceived heterogeneity (difference) of patients with chronic non-specific low back pain. It is felt that the effects of treatment may be diluted by the application of a single intervention to a complex, heterogeneous group with diverse treatment needs. This argument presupposes that current treatment is effective when applied to the correct patient.”
The authors of the paper also stated, “An alternative perspective is that the clinical trials are correct and current treatments have limited efficacy. This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials.”
Interestingly the argument for “subgroups”, which we do appreciate, is used to refute these studies results, when in fact it only reinforces them along with the overall message of this article. In that, it’s completely inaccurate and mentally lazy to simply make blanket associations between things like: pelvic tilts, spinal curves, posture habits, etc., as consistent and repeatable predisposing/maintaining factors for lower back pain.”
I think it is very important to state that because psychosocial factors are important in the development chronic pain and disability (51), and depression, passive coping strategies, fear avoidance beliefs (the avoidance of movement or activity resulting from fear of pain or injury), are associated with poor outcome.
Because of this, what clinicians or personal trainers say to their clients can have a negative effect on their pain, and help to reinforced their belief that their spine is vulnerable. Clinicians should not focus on pathoanatomic (16, 51) explanations for the cause of the clients pain, and there are recommendations against doing this (16, 51, 52, 53).
Lars’ references will be listed below. From here we’ll move onto Jason’s evaluation of one of the references that Ellen used to support her argument:
Ellen Buckley claims in her rebuttal article that “Poor sitting posture has been consistently shown to be a strong predictor of low back pain ” This study does not support her point.
The Stankovic and Johnell article in Spine from 1990 (called Stankovic 1990 from now on) was not an observational study that revealed poor sitting posture as a predictor of low back pain.
Stankovic 1990 was an intervention study in those with acute low back comparing two treatments: “McKenzie treatment” and a “Mini Back School” education intervention with results out to one year. Not only was there no evidence in this study that sitting posture was predictive for back pain, this study did not actually follow a McKenzie assessment and treatment process. The “McKenzie” intervention was a protocol of exercises that were extension-based and the only attempt at individualizing the treatment was the correction of any lateral deviation. While these are all commonly used procedures in the McKenzie Mechanical Diagnosis and Therapy (MDT) process, it is certainly not the individualized assessment and treatment that MDT uses. I briefly discussed the process of care that is involved in MDT and in manual therapy treatment in an editorial you can find in full text here
The existing evidence in physical medicine does not show any clear value of static postural assessment either in prediction or treatment. If such a claim is made, appropriate evidence to support it must be provided – perhaps Ms Buckley could provide another study for this finding that is “consistently” observed. Certainly an assessment with such limited value should not be reserved for those with a physical therapy educational background, either.
Dr Shirley Sahrmann, whose specialized assessment and treatment of musculoskeletal problems relies on postural assessment, has herself acknowledged that the literature has not been kind to static postural assessment in an editorial in 2002: It seems that the last 12 years have not seen the literature change with respect to postural assessments – I wonder when we can expect clinicians’ opinions and practice to change?
Jason Silvernail DPT, DSc, FAAOMPT
1.Walker ML, Rothstein JM, Finucane SD, Lamb RL. Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance. Phys Ther. 1987 Apr;67(4):512-6. PubMed PMID: 2951745.
2. DiVeta J, Walker ML, Skibinski B. Relationship between performance of selected scapular muscles and scapular abduction in standing subjects. Phys Ther. 1990 Aug;70(8):470-6; discussion 476-9. PubMed PMID: 2374776.
3. Cook DJ, Guyatt GH, Laupacis A, Sackett DL, Goldberg RJ. Clinical recommendations using levels of evidence for antithrombotic agents. Chest 1995 Oct; 108(4 Suppl):227S-230S.
4. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003 Jan;85-A(1):1-3.
5. Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine (Phila Pa 1976). 1987 Sep;12(7):632-44.
6. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965; 150: 971–79.
7. Loeser JD, Melzack R. Pain: an overview. Lancet. 1999 May 8;353(9164):1607-9.
8. Melzack R. From the gate to the neuromatrix. Pain. 1999 Aug;Suppl 6:S121-6.
9. Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther. 2003 Aug;8(3):130-40.
10. Melzack R. Evolution of the neuromatrix theory of pain. The Prithvi Raj Lecture: presented at the third World Congress of World Institute of Pain, Barcelona 2004. Pain Pract. 2005 Jun;5(2):85-94.
11. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007 Jul;133(4):581-624.
12. Gatchel RJ, Turk DC. Criticisms of the biopsychosocial model in spine care: creating and then attacking a straw person. Spine (Phila Pa 1976). 2008 Dec 1;33(25):2831-6.
13. Moseley GL. Pain, brain imaging and physiotherapy–opportunity is knocking. Man Ther. 2008 Dec;13(6):475-7.
14. Leung L. From ladder to platform: a new concept for pain management. J Prim Health Care. 2012 Sep 1;4(3):254-8.
15. Moseley, G. Lorimer. Teaching people about pain: why do we keep beating around the bush? Pain Manage. (2012) 2(1), 1–3.
16. Delitto A, George SZ, Van Dillen LR, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):A1-57. Epub 2012 Mar 30.
17. Melzack R., Katz J. (2013), Pain. WIREs Cogn Sci, 4: 1–15.
18. Loeser JD, Cahana A. Pain medicine versus pain management: ethical dilemmas created by contemporary medicine and business. Clin J Pain. 2013 Apr;29(4):311-6.
19. NACHEMSON, ALF L. MD. Disc Pressure Measurements. Spine (Phila Pa 1976). 1981 Jan-Feb;6(1):93-7.
20. Wilke HJ, Neef P, Caimi M, Hoogland T, Claes LE. New in vivo measurements of pressures in the intervertebral disc in daily life. Spine (Phila Pa 1976). 1999 Apr 15;24(8):755-62.
21. Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. 2011 Apr;15(2):131-8. PubMed PMID: 21419349.
22. Edmondston SJ, Chan HY, Ngai GC, Warren ML, Williams JM, Glennon S, Netto K. Postural neck pain: an investigation of habitual sitting posture, perception of ‘good’ posture and cervicothoracic kinaesthesia. Man Ther. 2007 Nov;12(4):363-71. PubMed PMID: 16963312.
23. Grimmer K. An investigation of poor cervical resting posture. Aust J Physiother. 1997;43(1):7-16.
24. Norton B.J., Sahrmann S.A., Van Dillen L.R. Differences in Measurements of Lumbar Curvature Related to Gender and Low Back Pain. J Orthop Sports Phys Ther. 2004;34(9):524-534.
25. Murrie V.L., Dixon A.K., Hollingworth W., Wilson H., Doyle T.A. Lumbar lordosis: study of patients with and without low back pain. Clin Anat. 2003 Mar;16(2):144-7.
26. Tüzün C., Yorulmaz I., Cindaş A., Vatan S. Low back pain and posture. Clin Rheumatol. 1999;18(4):308-12.
27. Evcik D., YÃ¼cel A. Lumbar lordosis in acute and chronic low back pain patients. Rheumatol Int. 2003 Jul;23(4):163-5. Epub 2003 Jan 18.
28. Evcik D., Yücel A. Lumbar lordosis in acute and chronic low back pain patients. Rheumatol Int. 2003 Jul;23(4):163-5. Epub 2003 Jan 18.
29. Nourbakhsh M.R., Arab A.M. Relationship Between Mechanical Factors and Incidence of Low Back Pain. J Orthop Sports Phys Ther. 2002; 32(9):447â€“460.
31. Kim H.J., Chung S., Kim S., Shin H., Lee J., Kim S., Song M.Y. Influences of trunk muscles on lumbar lordosis and sacral angle. Eur Spine J. 2006 Apr;15(4):409-14. Epub 2005 Sep 7.
32. 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.
33. Edmondston SJ, Chan HY, Ngai GC, Warren ML, Williams JM, Glennon S, Netto K. Postural neck pain: an investigation of habitual sitting posture, perception of ‘good’ posture and cervicothoracic kinaesthesia. Man Ther. 2007 Nov;12(4):363-71. PubMed PMID: 16963312.
34. Christensen ST, Hartvigsen J. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):690-714. doi: 10.1016/j.jmpt.2008.10.004.
Grob D, Frauenfelder H, Mannion AF. The association between cervical spine curvature and neck pain. Eur Spine J. 2007 May;16(5):669-78. Epub 2006 Nov 18.
35. Mitchell T, O’Sullivan PB, Burnett AF, Straker L, Smith A. Regional differences in lumbar spinal posture and the influence of low back pain. BMC Musculoskelet Disord. 2008 Nov 18;9:152.
36. Smith A, O’Sullivan P, Straker L. Classification of sagittal thoraco-lumbo-pelvic alignment of the adolescent spine in standing and its relationship to low back pain. Spine (Phila Pa 1976). 2008 Sep 1;33(19):2101-7. doi: 10.1097/BRS.0b013e31817ec3b0.
37. Matheus RA, Ramos-Perez FM, Menezes AV, Ambrosano GM, Haiter-Neto F, Bóscolo FN, de Almeida SM. The relationship between temporomandibular dysfunction and head and cervical posture. J Appl Oral Sci. 2009 May-Jun;17(3):204-8.
38. Yip CH, Chiu TT, Poon AT. The relationship between head posture and severity and disability of patients with neck pain. Man Ther. 2008 May;13(2):148-54. Epub 2007 Mar 23.
39. Moseley GL, Parsons TJ, Spence C. Visual distortion of a limb modulates the pain and swelling evoked by movement. Curr Biol. 2008 Nov 25;18(22):R1047-8.
40. Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain. 2007 Dec 15;133(1-3):64-71. Epub 2007 Apr 20.
41. BEECHER HK. Relationship of significance of wound to pain experienced. J Am Med Assoc. 1956 Aug 25;161(17):1609-13.
42. Bayer TL, Coverdale JH, Chiang E, Bangs M. The role of prior pain experience and expectancy in psychologically and physically induced pain. Pain. 1998 Feb;74(2-3):327-31.
43. Roehrs TA; Harris E; Randall S; Roth T. Pain sensitivity and recovery from mild chronic sleep loss. SLEEP 2012;35(12):1667-1672.
44. Moseley GL. Imagined movements cause pain and swelling in a patient with complex regional pain syndrome. Neurology. 2004 May 11;62(9):1644.
45. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009 Jan;89(1):9-25. Epub 2008 Dec 4.
46. MacDonald DA, Moseley GL, Hodges PW. The lumbar multifidus: does the evidence support clinical beliefs? Man Ther. 2006 Nov;11(4):254-63. Epub 2006 May 23.
47. Kavcic N, Grenier S, McGill SM. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine (Phila Pa 1976). 2004 Jun 1;29(11):1254-65.
48. Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabil. 2007 Jan;88(1):54-62.
49. Allison GT, Morris SL. Transversus abdominis and core stability: has the pendulum swung? Br J Sports Med. 2008 Nov;42(11):930-1. Epub 2008 Jul 4.
50. Wand BM, O’Connell NE. Chronic non-specific low back pain – sub-groups or a single mechanism? BMC Musculoskelet Disord. 2008 Jan 25;9:11.
51. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013 Nov-Dec;11(6):527-34.
52. Lang EV, Hatsiopoulou O, Koch T, Berbaum K, Lutgendorf S, Kettenmann E, Logan H, Kaptchuk TJ. Can words hurt? Patient-provider interactions during invasive procedures. Pain. 2005 Mar;114(1-2):303-9. Epub 2005 Jan 26.
53. Richter M, Eck J, Straube T, Miltner WH, Weiss T. Do words hurt? Brain activation during the processing of pain-related words. Pain. 2010 Feb;148(2):198-205. Epub 2009 Oct 28.