Posture review
Posture: A review of the science. The history of posture The idea of ‘good’ posture is as old as recorded history, with ancient Egyptian statues depicting gods and humans sitting perfectly upright and erect. In the latter half of the nineteenth century the idea of exercises to ‘correct’ posture came to prominence with the Swedish medical gymnastics movement led by Pehr Henrik Ling (Nicholls, 2017, p. 189). Physiotherapists adopted these ideas in the early and middle part of the twentieth century, and several textbooks were written on the subject by prominent physiotherapists e.g. Kendall first published in 1949 (Kendall & Kendall, 1949).
Figure 1: Statue of seated Pharaoh 1900 BC
These books described ‘ideal’ posture and common ‘faulty’ or ‘incorrect’ postures and related faulty posture to poor health, injury and pain. Postural correction was thus established firmly as one of the key modalities of physiotherapy in the middle part of the twentieth century (Nicholls, 2017, pp. 155-164). At this same time, Joseph Pilates was developing his ideas, and he was influenced both by medical gymnastics and current concepts in physiotherapy. His first book ‘Your Health’ published in 1934, describes ‘ideal’ and ‘faulty’ postures (Pilates, 1934).
Figure 2: Medical gymnastics circa 1900
www.breathe.edu.au
Testing ideas about posture Although widely accepted by health practitioners and the public since the middle part of the twentieth century, the idea of posture being related to health, injury and pain was first tested scientifically in the latter part of the twentieth century with researchers examining the relationship between posture, function, injury and pain in various body parts. Figure 3: Magazine advice on posture circa 1960
Is there such a thing as normal posture? Researchers consistently find a wide range of postures in pain-free people, as well as predictable changes across the lifespan; after age 60 lumbar curve generally flattens and forward head posture increases (Hey et al., 2017; Yoshida et al., 2014; Yukawa et al., 2016). Further, it seems that posture is not fixed for each person, and that people adopt different postures at different times (Dunk, Chung, Compton, & Callaghan, 2004; Dunk, Lalonde, & Callaghan, 2005; Robert A. Laird, Kent, & Keating, 2016).
Is posture related to muscle balance? Walker, Rothstein, Finucane, and Lamb (1987) studied the relationship between lumbar lordosis, pelvic tilt and lower abdominal strength (measured by the Kendall straight leg lowering test) and found no association. This finding was echoed by Youdas, Garrett, Harmsen, Suman, and Carey (1996). Flint (1963) found no relationship between lumbar lordosis and either hip flexibility or abdominal strength. Mulhearn and George (1999) found no relationship between abdominal endurance and posture. A 1996 study did find a reduction in lumbar lordosis after a comprehensive stretching and strengthening program (Alizadeh & Standring, 1996), as did a 2003 study (Scannell & McGill, 2003). Whereas a 2-year program of isometric strengthening of the back extensors did not change radiographic measurement of thoracic kyphosis in postmenopausal women (Itoi & Sinaki, 1994). In the shoulder, a 1999 study found no change in resting scapular position after a 6 week strengthening and stretching program (Wang, McClure, Pratt, & Nobilini, 1999). And there appears to be no correlation between rounded shoulders and shortness of the pectoralis major or minor muscles in college women (Coppock, 1958).
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In their review of resistance exercise and postural alignment Hrysomallis and Goodman (2001) concluded: “Based on the review of existing literature, it is inadvisable to strongly promote strengthening exercises to correct postural malalignments, such as abducted scapulae, excessive lumbar lordosis, scoliosis, or kyphosis.”
Does ‘abnormal’ posture cause pain? A 2017 meta-analysis found decreased lumbar curve was strongly related to low back pain (Chun, Lim, Kim, Hwang, & Chung, 2017). This meta-analysis reviewed only studies that measured lordosis by radiograph (X-ray, CT, MRI) which is extremely accurate but only measures at a single point in time so does not capture people’s habitual posture after standing for several hours. Another systematic review and meta-analysis, this one from 2014, found absolutely no relationship between lumbar curve and low back pain (Robert A Laird, Gilbert, Kent, & Keating, 2014). Why the difference? Where the 2017 review included only radiographic studies, the 2014 review only included studies that measured lordosis or pelvic tilt by skin surface instruments (e.g. inclinometer, reflective markers, plumb line). These measures are not as accurate as radiograph, but they are the measures that are used clinically by health professionals. They can also be used to measure posture over extended periods of standing or sitting that mimic everyday life situations e.g. (Scannell & McGill, 2003). A 2008 systematic review found no association between neck or shoulder pain and any particular sitting posture, but that long periods spent in any static posture were predictive of pain in adolescents (Prins, Crous, & Louw, 2008). This finding was replicated by a 2016 systematic review, which found no relationship between thoracic posture and shoulder pain (Barrett, O'Keeffe, O'Sullivan, Lewis, & McCreesh, 2016).
Maybe ‘which posture is best’ is the wrong question Rather than adopting any particular posture, there is some evidence that people with low back pain have less variability in their posture – that is to say they adopt a more rigid posture (Brumagne, Janssens, Knapen, Claeys, & Suuden-Johanson, 2008), move more slowly and bend more at the hip and less at the lumbar spine through mid-range flexion (Robert A Laird et al., 2014; Robert A. Laird et al., 2016). Perhaps which posture you stand or sit in is less important than how often you change position.
www.breathe.edu.au
Does changing posture affect pain? There is strong evidence from randomised controlled trials that exercise interventions aimed at changing posture have no more effect on back pain than general strengthening exercise. In fact it seems likely that specific muscle training and postural correction exercise has a slightly smaller effect on back pain than generalised whole body and trunk strengthening (Searle, Spink, Ho, & Chuter, 2015). The situation is similar when it comes to evidence on shoulder posture in relation to shoulder impingement. A 2013 systematic review concluded that rehabilitation of the scapula to an idealised normal posture is not supported by the available literature (Ratcliffe, Pickering, McLean, & Lewis, 2013).
Summary Humans have long been fascinated with ‘good’ and ‘bad’ posture, but most claims in relation to posture have very poor support from science: • • • • • • •
Tests available in the clinic are not able to meaningfully measure posture Pain free people exhibit a wide range of ‘normal’ postures Each person’s posture changes throughout the day, and over the lifespan Posture is not an indicator of muscle length or strength Strengthening and stretching programs probably do not alter posture much Posture is poorly correlated with pain, if at all Holding any static posture for prolonged periods can be painful
What DOES make a difference for musculoskeletal pain? Here are the things we currently know have a consistent positive effect for low back pain (Brooks et al., 2003; Schug, Palmer, Scott, Halliwell, & Trinca, 2015): • • • •
Reassurance Advice to stay active General, graded exercise Heat
www.breathe.edu.au
References Alizadeh, M. H., & Standring, J. (1996). The effect of an exercise regime on lumbar spine curve. The engineering of sport, 31-35. Barrett, E., O'Keeffe, M., O'Sullivan, K., Lewis, J., & McCreesh, K. (2016). Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Manual Therapy, 26(Supplement C), 38-46. doi:https://doi.org/10.1016/j.math.2016.07.008 Brooks, P., March, L., Bogduk, N., Bellamy, N., Spearing, N., Fraser, M., . . . Blyth, F. (2003). Evidence-based management of acute musculoskeletal pain: Australian Academic Press. Brumagne, S., Janssens, L., Knapen, S., Claeys, K., & Suuden-Johanson, E. (2008). Persons with recurrent low back pain exhibit a rigid postural control strategy. European Spine Journal, 17(9), 1177-1184. Chun, S.-W., Lim, C.-Y., Kim, K., Hwang, J., & Chung, S. G. (2017). The relationships between low back pain and lumbar lordosis: a systematic review and metaanalysis. The Spine Journal. Coppock, D. E. (1958). Relationship of tightness of pectoral muscles to round shoulders in college women. Research Quarterly. American Association for Health, Physical Education and Recreation, 29(2), 146-153. Dunk, N. M., Chung, Y. Y., Compton, D. S., & Callaghan, J. P. (2004). The reliability of quantifying upright standing postures as a baseline diagnostic clinical tool. Journal of manipulative and physiological therapeutics, 27(2), 91-96. Dunk, N. M., Lalonde, J., & Callaghan, J. P. (2005). Implications for the use of postural analysis as a clinical diagnostic tool: reliability of quantifying upright standing spinal postures from photographic images. Journal of manipulative and physiological therapeutics, 28(6), 386-392. Flint, M. M. (1963). Lumbar posture: a study of roentgenographic measurement and the influence of flexibility and strength. Research Quarterly. American Association for Health, Physical Education and Recreation, 34(1), 15-20. Hey, H. W. D., Lau, E. T.-C., Wong, G. C., Tan, K.-A., Liu, G. K.-P., & Wong, H.-K. (2017). Cervical Alignment Variations in Different Postures and Predictors of Normal Cervical Kyphosis: A New Understanding. Spine, 42(21), 1614-1621. doi:10.1097/brs.0000000000002160 Hrysomallis, C., & Goodman, C. (2001). A review of resistance exercise and posture realignment. The Journal of Strength & Conditioning Research, 15(3), 385-390. Itoi, E., & Sinaki, M. (1994). Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Paper presented at the Mayo Clinic Proceedings. Kendall, H. O., & Kendall, F. P. (1949). Muscles. Testing And Function: LWW. 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. Laird, R. A., Kent, P., & Keating, J. L. (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. doi:10.1186/s12891-016-1250-1
www.breathe.edu.au
Mulhearn, S., & George, K. (1999). Abdominal muscle endurance and its association with posture and low back pain: An initial investigation in male and female elite gymnasts. Physiotherapy, 85(4), 210-216. Nicholls, D. A. (2017). The End of Physiotherapy: Routledge. Pilates, J. H. (1934). Your Health, Incline Village, Nev: Presentation Dynamics. Inc., 1998 (First Published, 1934), 11. Prins, Y., Crous, L., & Louw, Q. (2008). A systematic review of posture and psychosocial factors as contributors to upper quadrant musculoskeletal pain in children and adolescents. Physiotherapy theory and practice, 24(4), 221-242. Ratcliffe, E., Pickering, S., McLean, S., & Lewis, J. (2013). Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Br J Sports Med, bjsports-2013-092389. Scannell, J. P., & McGill, S. M. (2003). Lumbar Posture—Should It, and Can It, Be Modified? A Study of Passive Tissue Stiffness and Lumbar Position During Activities of Daily Living. Physical therapy, 83(10), 907-917. doi:10.1093/ptj/83.10.907 Schug, S. A., Palmer, G. M., Scott, D. A., Halliwell, R., & Trinca, J. (2015). Acute Pain Management: Scientific Evidence (4th edition). Melbourne: ANZCA & FPM. Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical rehabilitation, 29(12), 1155-1167. Walker, M. L., Rothstein, J. M., Finucane, S. D., & Lamb, R. L. (1987). Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance. Physical therapy, 67(4), 512-516. Wang, C.-H., McClure, P., Pratt, N. E., & Nobilini, R. (1999). Stretching and strengthening exercises: their effect on three-dimensional scapular kinematics. Archives of physical medicine and rehabilitation, 80(8), 923-929. Yoshida, G., Yasuda, T., Togawa, D., Hasegawa, T., Yamato, Y., Kobayashi, S., . . . Matsuyama, Y. (2014). Craniopelvic alignment in elderly asymptomatic individuals: analysis of 671 cranial centers of gravity. Spine, 39(14), 1121-1127. Youdas, J. W., Garrett, T. R., Harmsen, S., Suman, V. J., & Carey, J. R. (1996). Lumbar lordosis and pelvic inclination of asymptomatic adults. Physical therapy, 76(10), 1066-1081. Yukawa, Y., Kato, F., Suda, K., Yamagata, M., Ueta, T., & Yoshida, M. (2016). Normative data for parameters of sagittal spinal alignment in healthy subjects: an analysis of gender specific differences and changes with aging in 626 asymptomatic individuals. European Spine Journal, 1-7.
www.breathe.edu.au
Figure 1: Statue of seated Pharaoh 1900 BC
These books described ‘ideal’ posture and common ‘faulty’ or ‘incorrect’ postures and related faulty posture to poor health, injury and pain. Postural correction was thus established firmly as one of the key modalities of physiotherapy in the middle part of the twentieth century (Nicholls, 2017, pp. 155-164). At this same time, Joseph Pilates was developing his ideas, and he was influenced both by medical gymnastics and current concepts in physiotherapy. His first book ‘Your Health’ published in 1934, describes ‘ideal’ and ‘faulty’ postures (Pilates, 1934).
Figure 2: Medical gymnastics circa 1900
www.breathe.edu.au
Testing ideas about posture Although widely accepted by health practitioners and the public since the middle part of the twentieth century, the idea of posture being related to health, injury and pain was first tested scientifically in the latter part of the twentieth century with researchers examining the relationship between posture, function, injury and pain in various body parts. Figure 3: Magazine advice on posture circa 1960
Is there such a thing as normal posture? Researchers consistently find a wide range of postures in pain-free people, as well as predictable changes across the lifespan; after age 60 lumbar curve generally flattens and forward head posture increases (Hey et al., 2017; Yoshida et al., 2014; Yukawa et al., 2016). Further, it seems that posture is not fixed for each person, and that people adopt different postures at different times (Dunk, Chung, Compton, & Callaghan, 2004; Dunk, Lalonde, & Callaghan, 2005; Robert A. Laird, Kent, & Keating, 2016).
Is posture related to muscle balance? Walker, Rothstein, Finucane, and Lamb (1987) studied the relationship between lumbar lordosis, pelvic tilt and lower abdominal strength (measured by the Kendall straight leg lowering test) and found no association. This finding was echoed by Youdas, Garrett, Harmsen, Suman, and Carey (1996). Flint (1963) found no relationship between lumbar lordosis and either hip flexibility or abdominal strength. Mulhearn and George (1999) found no relationship between abdominal endurance and posture. A 1996 study did find a reduction in lumbar lordosis after a comprehensive stretching and strengthening program (Alizadeh & Standring, 1996), as did a 2003 study (Scannell & McGill, 2003). Whereas a 2-year program of isometric strengthening of the back extensors did not change radiographic measurement of thoracic kyphosis in postmenopausal women (Itoi & Sinaki, 1994). In the shoulder, a 1999 study found no change in resting scapular position after a 6 week strengthening and stretching program (Wang, McClure, Pratt, & Nobilini, 1999). And there appears to be no correlation between rounded shoulders and shortness of the pectoralis major or minor muscles in college women (Coppock, 1958).
www.breathe.edu.au
In their review of resistance exercise and postural alignment Hrysomallis and Goodman (2001) concluded: “Based on the review of existing literature, it is inadvisable to strongly promote strengthening exercises to correct postural malalignments, such as abducted scapulae, excessive lumbar lordosis, scoliosis, or kyphosis.”
Does ‘abnormal’ posture cause pain? A 2017 meta-analysis found decreased lumbar curve was strongly related to low back pain (Chun, Lim, Kim, Hwang, & Chung, 2017). This meta-analysis reviewed only studies that measured lordosis by radiograph (X-ray, CT, MRI) which is extremely accurate but only measures at a single point in time so does not capture people’s habitual posture after standing for several hours. Another systematic review and meta-analysis, this one from 2014, found absolutely no relationship between lumbar curve and low back pain (Robert A Laird, Gilbert, Kent, & Keating, 2014). Why the difference? Where the 2017 review included only radiographic studies, the 2014 review only included studies that measured lordosis or pelvic tilt by skin surface instruments (e.g. inclinometer, reflective markers, plumb line). These measures are not as accurate as radiograph, but they are the measures that are used clinically by health professionals. They can also be used to measure posture over extended periods of standing or sitting that mimic everyday life situations e.g. (Scannell & McGill, 2003). A 2008 systematic review found no association between neck or shoulder pain and any particular sitting posture, but that long periods spent in any static posture were predictive of pain in adolescents (Prins, Crous, & Louw, 2008). This finding was replicated by a 2016 systematic review, which found no relationship between thoracic posture and shoulder pain (Barrett, O'Keeffe, O'Sullivan, Lewis, & McCreesh, 2016).
Maybe ‘which posture is best’ is the wrong question Rather than adopting any particular posture, there is some evidence that people with low back pain have less variability in their posture – that is to say they adopt a more rigid posture (Brumagne, Janssens, Knapen, Claeys, & Suuden-Johanson, 2008), move more slowly and bend more at the hip and less at the lumbar spine through mid-range flexion (Robert A Laird et al., 2014; Robert A. Laird et al., 2016). Perhaps which posture you stand or sit in is less important than how often you change position.
www.breathe.edu.au
Does changing posture affect pain? There is strong evidence from randomised controlled trials that exercise interventions aimed at changing posture have no more effect on back pain than general strengthening exercise. In fact it seems likely that specific muscle training and postural correction exercise has a slightly smaller effect on back pain than generalised whole body and trunk strengthening (Searle, Spink, Ho, & Chuter, 2015). The situation is similar when it comes to evidence on shoulder posture in relation to shoulder impingement. A 2013 systematic review concluded that rehabilitation of the scapula to an idealised normal posture is not supported by the available literature (Ratcliffe, Pickering, McLean, & Lewis, 2013).
Summary Humans have long been fascinated with ‘good’ and ‘bad’ posture, but most claims in relation to posture have very poor support from science: • • • • • • •
Tests available in the clinic are not able to meaningfully measure posture Pain free people exhibit a wide range of ‘normal’ postures Each person’s posture changes throughout the day, and over the lifespan Posture is not an indicator of muscle length or strength Strengthening and stretching programs probably do not alter posture much Posture is poorly correlated with pain, if at all Holding any static posture for prolonged periods can be painful
What DOES make a difference for musculoskeletal pain? Here are the things we currently know have a consistent positive effect for low back pain (Brooks et al., 2003; Schug, Palmer, Scott, Halliwell, & Trinca, 2015): • • • •
Reassurance Advice to stay active General, graded exercise Heat
www.breathe.edu.au
References Alizadeh, M. H., & Standring, J. (1996). The effect of an exercise regime on lumbar spine curve. The engineering of sport, 31-35. Barrett, E., O'Keeffe, M., O'Sullivan, K., Lewis, J., & McCreesh, K. (2016). Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Manual Therapy, 26(Supplement C), 38-46. doi:https://doi.org/10.1016/j.math.2016.07.008 Brooks, P., March, L., Bogduk, N., Bellamy, N., Spearing, N., Fraser, M., . . . Blyth, F. (2003). Evidence-based management of acute musculoskeletal pain: Australian Academic Press. Brumagne, S., Janssens, L., Knapen, S., Claeys, K., & Suuden-Johanson, E. (2008). Persons with recurrent low back pain exhibit a rigid postural control strategy. European Spine Journal, 17(9), 1177-1184. Chun, S.-W., Lim, C.-Y., Kim, K., Hwang, J., & Chung, S. G. (2017). The relationships between low back pain and lumbar lordosis: a systematic review and metaanalysis. The Spine Journal. Coppock, D. E. (1958). Relationship of tightness of pectoral muscles to round shoulders in college women. Research Quarterly. American Association for Health, Physical Education and Recreation, 29(2), 146-153. Dunk, N. M., Chung, Y. Y., Compton, D. S., & Callaghan, J. P. (2004). The reliability of quantifying upright standing postures as a baseline diagnostic clinical tool. Journal of manipulative and physiological therapeutics, 27(2), 91-96. Dunk, N. M., Lalonde, J., & Callaghan, J. P. (2005). Implications for the use of postural analysis as a clinical diagnostic tool: reliability of quantifying upright standing spinal postures from photographic images. Journal of manipulative and physiological therapeutics, 28(6), 386-392. Flint, M. M. (1963). Lumbar posture: a study of roentgenographic measurement and the influence of flexibility and strength. Research Quarterly. American Association for Health, Physical Education and Recreation, 34(1), 15-20. Hey, H. W. D., Lau, E. T.-C., Wong, G. C., Tan, K.-A., Liu, G. K.-P., & Wong, H.-K. (2017). Cervical Alignment Variations in Different Postures and Predictors of Normal Cervical Kyphosis: A New Understanding. Spine, 42(21), 1614-1621. doi:10.1097/brs.0000000000002160 Hrysomallis, C., & Goodman, C. (2001). A review of resistance exercise and posture realignment. The Journal of Strength & Conditioning Research, 15(3), 385-390. Itoi, E., & Sinaki, M. (1994). Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Paper presented at the Mayo Clinic Proceedings. Kendall, H. O., & Kendall, F. P. (1949). Muscles. Testing And Function: LWW. 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. Laird, R. A., Kent, P., & Keating, J. L. (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. doi:10.1186/s12891-016-1250-1
www.breathe.edu.au
Mulhearn, S., & George, K. (1999). Abdominal muscle endurance and its association with posture and low back pain: An initial investigation in male and female elite gymnasts. Physiotherapy, 85(4), 210-216. Nicholls, D. A. (2017). The End of Physiotherapy: Routledge. Pilates, J. H. (1934). Your Health, Incline Village, Nev: Presentation Dynamics. Inc., 1998 (First Published, 1934), 11. Prins, Y., Crous, L., & Louw, Q. (2008). A systematic review of posture and psychosocial factors as contributors to upper quadrant musculoskeletal pain in children and adolescents. Physiotherapy theory and practice, 24(4), 221-242. Ratcliffe, E., Pickering, S., McLean, S., & Lewis, J. (2013). Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Br J Sports Med, bjsports-2013-092389. Scannell, J. P., & McGill, S. M. (2003). Lumbar Posture—Should It, and Can It, Be Modified? A Study of Passive Tissue Stiffness and Lumbar Position During Activities of Daily Living. Physical therapy, 83(10), 907-917. doi:10.1093/ptj/83.10.907 Schug, S. A., Palmer, G. M., Scott, D. A., Halliwell, R., & Trinca, J. (2015). Acute Pain Management: Scientific Evidence (4th edition). Melbourne: ANZCA & FPM. Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical rehabilitation, 29(12), 1155-1167. Walker, M. L., Rothstein, J. M., Finucane, S. D., & Lamb, R. L. (1987). Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance. Physical therapy, 67(4), 512-516. Wang, C.-H., McClure, P., Pratt, N. E., & Nobilini, R. (1999). Stretching and strengthening exercises: their effect on three-dimensional scapular kinematics. Archives of physical medicine and rehabilitation, 80(8), 923-929. Yoshida, G., Yasuda, T., Togawa, D., Hasegawa, T., Yamato, Y., Kobayashi, S., . . . Matsuyama, Y. (2014). Craniopelvic alignment in elderly asymptomatic individuals: analysis of 671 cranial centers of gravity. Spine, 39(14), 1121-1127. Youdas, J. W., Garrett, T. R., Harmsen, S., Suman, V. J., & Carey, J. R. (1996). Lumbar lordosis and pelvic inclination of asymptomatic adults. Physical therapy, 76(10), 1066-1081. Yukawa, Y., Kato, F., Suda, K., Yamagata, M., Ueta, T., & Yoshida, M. (2016). Normative data for parameters of sagittal spinal alignment in healthy subjects: an analysis of gender specific differences and changes with aging in 626 asymptomatic individuals. European Spine Journal, 1-7.
www.breathe.edu.au
