Posture: the ongoing debate

Posture, wow it’s a popular topic, particularly in primary and community healthcare. You literally can’t go a day without seeing something that relates to improving or “correcting” your posture. Your health professional (that’s physio, chiro, osteo, pilates teacher, massage therapist, personal trainer, the media) has I’m sure at one time talked to you about posture and what is “good” posture. Advising you on symmetry and how muscle imbalances or joint mis-alignments need “correcting” as these things lead to “pain” and long term musculoskeletal problems.

When you go to work, there is any number of ergonomic devices – chairs, tables, forearm supports etc to help reduce the “stress” on your muscles and joints and to help you maintain a “good” posture so to reduce the mechanical load on tissue, which apparently leads to a litany of musculoskeletal related disorders. Typing in posture on google brings up 77 million results the majority of which point to how to “fix” it or training your body to stand, walk, sit and lie in positions where the least strain is place on supporting muscles and ligament.

Incidentally, who decided that your spine should be straight when you go to sleep? That you need an orthopaedic mattress or pillow to support your back/neck?

The problem with all these mechanical ideologies is that they don’t hold up against the evidence. Gawke, Gorgievski, & van der Linden, (2012) identified that social support, information processing and task interdependence were better predictors of complaints of arms, neck and shoulder pain in office workers. Turner et al., (2006) identified two psychosocial variables as predictors of ongoing physical disability and failure to return to work over physical factors. This being recovery expectations and work fear-avoidance, not posture. Roffey, Wai, Bishop, Kwon, & Dagenais, (2010) found there was strong evidence for consistency of no association between awkward occupational postures and LBP. So, people who did not adopt a “good” posture were no more at risk of developing back pain. Interestingly another study (Claus, Hides, Moseley, & Hodges, 2016) found that people without any kind of back pain actually slumped whilst sitting and that it was not a causal link to pain. Finally, you might be interested to know that a study found that static compression (keep your back still) had a catabolic effect (breaking down) on our spinal discs (Wang, Jiang, & Dai, 2007).

The other problem with these ideologies is that they continue to see the body as a machine. The body is placed under mechanical load (like a crane) and that adds stress to your joints, limb, muscles, discs and they begin to “wear out”. Jeez we are not pieces of rubber or fabric we are a bit more resilient than that! I will reiterate what many other blogs have said. Posture is not static it is dynamic, therefore it is unavoidable to not be in an “optimal” posture throughout your day, as it is constantly changing. There are subtle changes occurring all the time.

Bending like a crane

Talking of cranes, the phrase ‘don’t bend your back like a crane’ is still common  in New Zealand.  I think it’s about time we revisited this understanding. One of the problems as I have experienced as a result of this phrase is the belief that all lifting (irrespective of the load) is bad for your back. I want to briefly discuss this.

There is a lot of evidence to show that lifting with the back is not so black and white. Bending your back is not necessarily bad (Holder, 2013; Kingma, Faber, & van Dieën, 2010; Potvin, McGill & Norman, 1991). Studies have found that lifting boxes in particular ways (back vs knees) found there was less load on the back and more efficient neuromuscular activity when lifting with the back.  Furthermore, it is commonly accepted that we should be lifting with our knees. Well, let me ask you, if there is a belief that your spine will wear out due to lifting with your back, then won’t your knees wear out if you lift with your knees? Is this not common sense if we adopt a mechanical model way of thinking?

Interestingly, a study found that bending your knees was no more protective of your back or prevented developing back pain than bending with your back (Van Dieën, Hoozemans, & Toussaint, 2000) another study found that with squatting there is still 40 degrees of lumbar flexion (Potvin, McGill & Norman, 1991) and a clinical commentary by Mawston, G & Boocock, M, (2012) explains that bending with the knees increased lumbar flexion more than bending with straight knees, resulting in less strain on the low back. Huh??? So, wait, let me get this straight. It seems that there is less strain on your back if you do bend it like a crane. So would this suggest that it is ok to bend your back like a crane?

Now, let’s just take a breath! First up, I’m not giving you a free pass to start bending your back for lifting.  Biomechanics for lifting may still be necessary under certain conditions. This might include when we have an acute back injury or that the load we are attempting to lift is beyond our capacity, therefore we might need to make adjustments to improve our ability. We may also need to consider how fatigued, overworked or stressed we may have been when attempting to lift. Secondly if there is something heavy that needs lifting it makes sense to use our legs (and also to get help from a colleague) and bend our knees not because we should protect our back but because we generate more power and force, thus generating energy transfer into our whole body, so making it easier and more efficient to lift the item in question.

Back to posture

Anyway, this blog is about posture not lifting, although the two do seem to go hand in hand. Posture is widely accepted as a cause of pain and also developing musculoskeletal conditions. The reason? As previously mentioned the body is viewed as a machine, that we need perfect alignment in our joints and balance in our opposing muscle groups so to minimize “wear” on the body. Apparently, there is an ideal posture and anything outside of this is viewed as bad. Talk about minimizing your opportunities for movement!

It identifies the ideal posture. Think about the message that this image projects it essentially says anything outside of a “good” posture is bad. In actual fact a recent study found that there is so much variability in lumbar lordosis throughout the day it is hard to determine what is normal from a standing assessment (Dreischarf, Pries, Bashkuev, Putzier, & Schmidt, 2016), and a further study found that lumbar lordosis was no different in people with and without back pain (Schmidt et al., 2017). So, in conclusion should we need to constantly think about our posture throughout the day. Perhaps in certain circumstances. However I would say there are far more important things to think about, like the next Star Wars movie being released or where you’re going for your next adventure.

Not sure about her posture!

Interestingly there are a number of studies that have examined specific factors that are popularly blamed as causative links to poor posture. This includes pelvic tilt, leg length discrepancies, lumbar lordosis, mis-alignments, muscle tightness and more. None of them and I mean none of them have been shown to have any strong causal link to posture and pain (Laird et al., 2016; Laird, Gilbert, Kent, & Keating, 2014; Lederman, 2010; Preece et al., 2008).

Let’s take this one step further, why is it that in the working population we are so concerned with posture and asymmetry but there are Olympic athletes like Usain Bolt and Jessica Ashwood that display huge variations in posture, place huge amounts of “mechanical” stress upon their bodies and yet can win gold medals? I challenge any healthcare professional to suggest that by “re-aligning” either of these athletes would improve their performance.

So, what else could be driving this neurotic behaviour for the perfect posture, and is there perhaps a bigger picture we need to look at? Well apart from what we read in trashy celeb magazines perhaps conversations need to be had amongst clinicians about what changes need to be considered when educating patients. Do we need to have more flexibility in our approach? I’m not going to go into this as there are plenty of blogs out there that talk about this side of the argument.  I’ll just give you a quote from a piece of research.

 

‘Advice received from clinicians to control posture, strengthen muscles, lift with certain techniques, or avoid pain provoking activities may reinforce patient perceptions that their back is a vulnerable structure which should be protected (Darlow, 2016)

 

Plus, there is an even bigger problem than posture that needs to be addressed.  Sedentary behaviour.  Sedentary behaviour is a huge issue (i’m sitting now writing this). Research has shown that it is likely to have a causal link to all-cause mortality (that’s all deaths that occur in a population, regardless of the cause) (Biddle et al., 2016; Chau et al., 2013). That being sedentary for over 4 hours a day and not doing enough activity (walking, sports, exercise, physical job) throughout the day increases mortality risks (Ekelund et al., 2016). So, my issue is that we continue to have so much focus on posture, yet we are ignoring a bigger problem. We can continue to go and see a professional who gives us all this great postural advice but then we go back to sitting or standing at our desks again. Perhaps the way we work occupationally (in some contexts) has to change?

Posture is communication

I’m more interested in an area of posture that none of the blogs I have read mention – communication.

Interestingly, posture is so much more than just the misunderstood misalignment of spinal joints outside of “optimal”. If we look at the psychology of posture it is a means of communication. Our behavior (along with other forms of communication) is expressed through our posture through a variety of means:

Interpersonal relations

personality traits such as confidence, submissiveness, and openness

Social standing

Current emotional states

Characteristics of temperament

The affective component of posture refers to how we express our thoughts and feelings through non-verbal means. It is claimed that 55% of non-verbal communication is expressed through our posture (Kleinsmith, De Silva, & Bianchi-Berthouze, 2006). However, without asking someone how they are feeling is it easy to presume that they might be in pain? Do we know the causal link to their pain? Is it from a misalignment of the joint? Or is it a result of an event that occurred in this person life that is then projected through their posture? The point is there is more to posture than just the poorly evidenced mechanical correlation health professionals continue to peddle.

Pain is a multi-dimensional experience and therefore not solely based upon physical factors. Treating someone through manipulation or correcting mis-alignments is unlikely to have a lasting effect if there are other underlying factors and from what we understand about how the nervous system and body adapts, trying to change something may have a negative effect. The interaction and social power of touch has a profound effect on someone who is sad, depressed, isolated and has back pain. Yet the naivety of the clinician to think that realigning spinal postures or lengthening muscles will “fix” an individual’s back pain, with the significant evidence base challenging the ideology is nothing short of clinicians practicing with self-serving beliefs.

That wraps up another blog from me.  Thanks for having a read.

 

TNP

 

References:

Biddle, S. J. H., Bennie, J. a, Bauman, A. E., Chau, J. Y., Dunstan, D., Owen, N., … van Uffelen, J. G. Z. (2016). Too much sitting and all-cause mortality: is there a causal link? BMC Public Health, 16, 635. https://doi.org/10.1186/s12889-016-3307-3

Chau, J. Y., Grunseit, A. C., Chey, T., Stamatakis, E., Brown, W. J., Matthews, C. E., … Van Der Ploeg, H. P. (2013). Daily sitting time and all-cause mortality: A meta-analysis. PLoS ONE, 8(11), 1–14. https://doi.org/10.1371/journal.pone.0080000

Claus, A. P., Hides, J. A., Moseley, G. L., & Hodges, P. W. (2016). Thoracic and lumbar posture behaviour in sitting tasks and standing: Progressing the biomechanics from observations to measurements. Applied Ergonomics. https://doi.org/10.1016/j.apergo.2015.09.006

Darlow, B. (2016). Beliefs about back pain: The confluence of client, clinician and community. International Journal of Osteopathic Medicine. https://doi.org/10.1016/j.ijosm.2016.01.005

Dreischarf, M., Pries, E., Bashkuev, M., Putzier, M., & Schmidt, H. (2016). Differences between clinical “snap-shot” and “real-life” assessments of lumbar spine alignment and motion – What is the “real” lumbar lordosis of a human being? https://doi.org/10.1016/j.jbiomech.2016.01.032

Ekelund, U., Steene-Johannessen, J., Brown, W. J., Wang Fagerland, M., Owen, N., Powell, K. E., … Lee, I.-M. (2016). Physical activity attenuates the detrimental association of sitting time with mortality: A harmonised meta-analysis of data from more than one million men and women for The Lancet Physical Activity Series Working Group* and the Lancet Sedentary Behaviour. Lancet, 388(1051), 1302–1310.

Gawke, J. C., Gorgievski, M. J., & van der Linden, D. (2012). Office work and complaints of the arms, neck and shoulders: The role of job characteristics, muscular tension and need for recovery. Journal of Occupational Health, 54(4), 323–330. https://doi.org/10.1539/joh.11-0152-OA

Holder, L. J. (2013). The Effect of Lumbar Posture and Pelvis Fixation on Back Extensor Torque and Paravertebral Muscle Activation.

Kingma, I., Faber, G. S., & van Dieën, J. H. (2010). How to lift a box that is too large to fit between the knees. Ergonomics, 53(10), 1228–1238. https://doi.org/10.1080/00140139.2010.512983

Kleinsmith, A., De Silva, P. R., & Bianchi-Berthouze, N. (2006). Cross-cultural differences in recognizing affect from body posture. Interacting with Computers, 18(6), 1371–1389. https://doi.org/10.1016/j.intcom.2006.04.003

Laird, R. A., Gilbert, J., Kent, P., & Keating, J. L. (2014). Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis. BMC Musculoskeletal Disorders, 15(1), 229. https://doi.org/10.1186/1471-2474-15-229

Laird, R. A., Kent, P., Keating, J. L., Vos, T., Flaxman, A., Naghavi, M., … Carman, A. (2016). How consistent are lordosis, range of movement and lumbo-pelvic rhythm in people with and without back pain? BMC Musculoskeletal Disorders, 17(1), 403. https://doi.org/10.1186/s12891-016-1250-1

Lederman, E. (2010). The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain. CPDO Online Journal, 1–14.

Mawston, G, A., & Boocock, M, G. (2012). The effect of lumbar posture on spinal loading and the function of the erector spinae : implications for exercise and vocational rehabilitation. New Zealand Journal of Physiotherapy, 40(3), 135–140.

Picavet, H. S. J., Pas, L. W., van Oostrom, S. H., van der Ploeg, H. P., Verschuren, W. M. M., & Proper, K. I. (2016). The Relation between Occupational Sitting and Mental, Cardiometabolic, and Musculoskeletal Health over a Period of 15 Years – The Doetinchem Cohort Study. Plos One, 11(1), e0146639. https://doi.org/10.1371/journal.pone.0146639

Potvin, J.R., McGill, S.M., Norman, R. W. (1991). Trunk Muscle and Lumbar Ligament Contributions to Dynamic Lifts with Varying Degrees of Trunk Flexion. Spine.

Preece, S. J., Willan, P., Nester, C. J., Graham-Smith, P., Herrington, L., & Bowker, P. (2008). Variation in pelvic morphology may prevent the identification of anterior pelvic tilt. The Journal of Manual & Manipulative Therapy, 16(2), 113–7. https://doi.org/10.1179/106698108790818459

Roffey, D. M., Wai, E. K., Bishop, P., Kwon, B. K., & Dagenais, S. (2010). Causal assessment of awkward occupational postures and low back pain: results of a systematic review. Spine Journal, 10(1), 89–99. https://doi.org/10.1016/j.spinee.2009.09.003

Schmidt, H., Bashkuev, M., Weerts, J., Graichen, F., Altenscheidt, J., Maier, C., & Reitmaier, S. (2017). How do we stand? Variations during repeated standing phases of asymptomatic subjects and low back pain patients. Journal of Biomechanics. https://doi.org/10.1016/j.jbiomech.2017.06.016

Turner, J. a, Franklin, G., Fulton-Kehoe, D., Sheppard, L., Wickizer, T. M., Wu, R., … Egan, K. (2006). Worker recovery expectations and fear-avoidance predict work disability in a population-based workers’ compensation back pain sample. Spine, 31(6), 682–689. https://doi.org/10.1097/01.brs.0000202762.88787.af

Van Dieën, J. H., Hoozemans, M. J. M., & Toussaint, H. M. (2000). A review of biomechanical studies on stoop and squat lifting. Proceedings of the XIVth Triennial Congress of the International Ergonomics Association and 44th Annual Meeting of the Human Factors and Ergonomics Association, “Ergonomics for the New Millennium,” 14, 643–646.

Wang, D.-L., Jiang, S.-D., & Dai, L.-Y. (2007). Biologic response of the intervertebral disc to static and dynamic compression in vitro. Spine, 32(23), 2521–2528. https://doi.org/10.1097/BRS.0b013e318158cb61

 

 

 

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