More Fitness. More Knowledge. More Results.

So you think you know how to measure and assess posture?

*notes: I don’t like the title ha, it sounds a bitty conceited but it did make you click and I figured it would be more interesting then “a thorough examination of the reliability of the visual assessment of the lumbar spine”. Anyways I think there is a valuable message here in examining the reliability of any practice you do as a trainer. Enjoy!

Justin

Posture; I haven’t talked about this subject in quite some time, frankly I’ve been spending more time focusing on learning more about strength training and programming. However, just because I haven’t really talked about it doesn’t mean I still haven’t been reading the research on it. In fact, Dr. Jonathan Fass and I are hopefully in the end phases of a research review on whether or not personal trainers should assess lumbar posture so it’s safe to say I’ve read a large percent of the relevant research on the subject.

Here’s the thing, I’m still noticing a lot of trainers talking about posture, specifically the alignment of the lumbar spine and its relationship to the pelvis (anterior pelvic tilt or posterior pelvic tilt). For simplicities sake let’s ignore the claims which include the alleged association between postural deviation and muscle imbalances and its association with pain and just focus on one question; as a personal trainer, do you really know how to assess lumbar posture? This means its accurate measurement and its change over time.

Let’s phrase this another way; your client wants to get stronger. You have a pretty good idea on how to measure a client’s strength. You might use the bench press or pull up for upper body strength or a leg press or squat for lower body strength. Now these are by no means gold standards for measuring strength but if a client can move more weight over time they have likely gotten stronger. So you have your assessment (leg press, squat, bench press, or whatever you decide to use) and you have your intervention which would be your training program. If your client gets stronger and they weren’t doing any training other than what you prescribed then your training program probably was the variable that changed their strength levels.

So you have your measure of strength which can be quantified by an actual number and your intervention which you predict will change the originally measured number. Now imagine how illogical it would be to say that you have a program that increases strength when you have no idea how to measure strength.

So before continuing to read ask yourself two questions (1) do you assess lumbar posture? And (2) do you know how lumbar posture is measured?

What is lumbar lordosis?

Lumbar lordosis refers to the anterior or inward curvature of the spine (Been).

How is lordosis measured and what is considered normal?

The problem with comparing data is that there are so many different ways people have measured lumbar lordosis. If you’re really interested check out this review by Vrtovec and colleagues. From what I’ve read, the Cobb method seems to be the standard. Cobbs method forms an angle by drawing a line at the superior endplate of L1 as well as a line at the superior endplate of the sacrum.

Cobb angle

So what’s normal?

This table comes from Roussouly, Gollogly, Berthonnaud, and Dimnet. They found that the average value for lordosis was 61.4 degrees with a range of 41.2 degrees to 81.9 degrees with the number of vertebrae contributing to the lordosis being between one and eight. They also identified four different classifications of lordosis.

Type 1 Type 2 Type 3 Type 4
Sacral slope Less than 35 degrees Less than 35 degrees Between 35 and 45 degrees Greater than 45 degrees
Lordosis range 41-64 degrees 44-58 degrees 43-76 degrees 61-82 degrees
Number of lordotic vertebrae 1.5-6 4-7.5 3-6.5 3.5-6
Prevalence 34 subjects 18 subjects 60 subjects 48 subjects

Type 3 is considered a well aligned spine but none of the individuals in this study, despite the wide range had back pain complaints.

Furthermore, Lin and colleagues also measured lumbar lordosis in a sample size of 149 subjects. The researchers discovered that the mean lordotic angle of this sample was 33.2 degrees. With one standard deviation, normal lordotic curve was 20-45 degrees. Lastly, Murrie and colleagues generated a modified Cobb angle by measuring the angle created from a line drawn between the L1/2 and L5/S1 disc spaces. The measured lordosis covered a wide range of 20 to 80 degrees.

I don’t remember the exact study but in the review section a researcher was quoted (okay I’m totally paraphrasing) as saying there is no point in defining normal spinal curvature due to large variations within the population.

Can it be accurately measured?

The answer is yes, lumbar lordosis can be accurately measured. Unfortunately just not by those still conducting visual assessments (which to my knowledge is the only way I’ve seen trainers do it). According to Vrtovec, Perus, and Likar examination of spinal curvature becomes more accurate when the evaluation is completely automated meaning relative to computerized evaluation, visual inspection is considered to be subjective, unreliable, and inconsistent (Vrtovec).

In fact there are several variables that might confound your visual analysis including gluteal prominence and stomach size. In a presentation I did this summer on the subject I had three pictures, two of them were of me and one was of another person. In one of the pictures of me I padded my butt with a towel to make it look bigger. I asked the people in the audience to rate who had a larger lordosis. The padded picture of me was rated as having a greater lumbar lordosis than the non padded picture. For example in this study by Mosner and colleagues titled,a comparision of actual and apparent lumbar lordosis in black and white adult females, they found that gluteal prominence played a role in how investigators perceived the size of a persons lumbar lordosis.

The reliability of visual inspection doesn’t get better from there but I urge you to figure this out for yourself by reading this (if you need the pdfs I can get them for you just message me or email me Justin.kompf90@gmail.com).

http://www.ncbi.nlm.nih.gov/pubmed/18796885

http://www.ncbi.nlm.nih.gov/pubmed/12923476

Here’s the bottom line, there are a wide variety of spinal curves that are all nonpathological and thus considered ‘normal’ although the fact that there are so many acceptable values makes the term normal basically useless. Next, research does not support the use of the visual assessment for posture. I’m going to list over 40 references below on lumbar lordosis, its measurement, association with pain, and muscle imbalances. If you’re a personal trainer and still evaluate spinal curvature I strongly urge (no insist) that you at least read some of these references from each category to evaluate your practice. I will be happy to supply pdfs if any readers want them.

Finally, don’t take this the wrong way. I am not saying lumbar posture is totally irrelevant. Some postures may be aesthetically unappealing to the person with said posture and some postures have been associated with pain (read Adams reference) although the evidence is not in favor of that claim. All I am saying here is that if you want to continue assessing lumbar posture please find a way to do it reliably.

Adams MA, Mannion AF, Dolan P. Personal risk factors for first time low back pain. Spine 24: 2497-2505, 1999.

Balague F, Mannion AF, Pellise F, and Cedraschi C. Non-specific low back pain. The Lancet 379: 482-491, 2012.

Battie MC, Bigos SJ, Fisher LD, Spengler DM, Hansson TH, Nachemson AL, Wortley MD. Anthropometric and clinical measures as predictors of back pain complaints in industry: A prospective study. J Spinal Disord 3: 195-204, 1990.

Been E and Kalichman L. Lumbar lordosis. Spine J 14: 87-97, 2014.

Britnell Sj, Cole JV, Isherwood L, Sran MM, Burgi S, Cardido G, and Watson L. Postural health in women: The role of physiotherapy. J Obstet Gynaecol Can 27: 493-510, 2005

Bryan JM, Mosner E, Shippee R, and Stull MA. Investigation of the validity of postural evaluation skills in assessing lumbar lordosis using photographs of clothed subjects. J Orthop Sports Phys Ther 12: 24-29, 1990.

Chaleat-Valayer E, Mac-Thiong JM, Paquet J, Berthonnaud E, Siani F, and Roussouly P. Sagittal spino-pelvic alignment in chronic low back pain. Eur Spine J 20: 634-640, 2011.

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 9: 690-714, 2008.

Christie HJ, Kumar S, Warren SA. Postural aberrations in low back pain. Arch Phys Med Rehabil 76: 218-224, 1995.

Clark M, Lucett S, and Sutton BG. NASM Essentials of Corrective Exercise Training. Philadelphia, PA: 2011.

Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 8: 8-20, 2008.

Deyo RA, Mirza SK, and Martin BI. Back pain prevalence and visit rates: Estimates from U.S. national surveys, 2002. Spine 31: 2724-2727, 2006.

Dunk NM, Lalonde J, and Callaghan JP. Implications for the use of the postural analysis as a clinical diagnostic tool: Reliability of quantifying upright standing spinal postures from photographic images. J Manipulative Physol Ther 28: 386-392, 2005.

During J, Goudfrooij H, Keessen W, Beeker TW, and Crowe A. Towards standards for posture. Postural characteristics of the lower back system in normal and pathological conditions. Spine 10: 83-87, 1985.

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4 responses

  1. Nicholas LaRocca, CSCS

    Hi Justin, first off interesting post, this is something that definitely applies to a vast majority of coaches out there myself included. As trainers and coaches we’re always toeing the line between textbook perfection and real world practicality. Do you have any suggestions for how to assess the lumbar spine with clients? What have you found that works well in your experiences?

    January 7, 2015 at 11:32 am

  2. justinkompf90

    Hey Nick, I don’t assess posture, like I said in the post it’s not reliable if done visually and I don’t have access to radiographs (nor would I do that for any of my athletes!) but here’s the thing, the postural assessment is based on a few things (1) that it’s going to cause pain- the evidence does not support this ( read the Christensen systematic review in the reference section) (2) that it impedes performance – it’s plausible but I haven’t seen evidence and (3) it’s caused by muscle imbalances ( strengthen weak lengthened muscles and stretc tight ones) – for the most of the evidence does not support the muscle imbalance theory. So I don’t recommend personal trainers do it as it is Unreliable with questionable validity and if anything else is outside of our scope of practice

    January 7, 2015 at 11:49 am

  3. Great post and refreshing to see the evidence sited. You may be interested to know that there is an even more accurate method to determine lumbar lordosis and it involves measuring the ‘relative rotation angles’ (RRA) between spinal vertebrae and then adding all the relative angles together.

    The one downfall of Cobbs is that it is only assessing the relative angle between upper and lower lumbar segments. So the RRA of L1/2+ L2/3 + L3/4 +L4/5 + L5/S1 is most accurate. For example, some lumbar spines might have a really large RRA at L5/S1 but a flat (alordotic) spine L1-4 and Cobb might call this within normal limits, although a large part of the curve is flat. There is a lot of good peer reviewed research using the RRA method. It is far more accurate but takes a lot longer to analyse the x-rays. There is now software to do this – yeah!

    Thanks again – great post!

    January 18, 2015 at 3:30 pm

    • justinkompf90

      Awesome, thank you I will check that out!

      January 18, 2015 at 9:39 pm

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