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Posture: Have we convicted the wrong suspect?

Updated: Jan 11

By Dave Emond


“Hey! Stop slouching! Stop looking down at your phone, that’s bad for you”.


“Sit up straight. Stop sitting with bad posture, you’ll get back and neck pain”.


“You need to set yourself up more ergonomically at work, this is why you keep going back to your manual therapist with persistent headaches, neck pain and low back pain”.


You’ve heard this. I’ve heard this. Heck, I’ve even said it. But just because something is widely believed to be true, it does not make it so. Remember when smoking was “good for you”?


So the popular narrative is that bad posture can cause pain, dysfunction and it will probably lead to “degenerative changes” (have a look at my previous article on that animal here).


Disclaimer:


Just for reference, I come from a purely biomechanical background. Throughout my entire education it was my firm belief that all pain had a specific mechanical source. It’s what I was taught. Prior to taking on the task of sifting through countless hours of research, I, like many of my colleagues, thought posture played a significant role in pain. So I’m laying my biases out in the open. Let’s you and I together see what the research says on posture and pain.


Is specific posture associated with pain?


A large scale prospective cohort study, one of the largest data-sets of its kind, was conducted in 2011 by Richards et al. to observe the association between neck postures and pain. They grouped participants into 4 postural categories ranging from the commonly termed “forward head posture/text neck” to an upright military posture, and analysed whether or not any of these 4 groups had a greater association with neck pain. Short answer: They didn’t. Although a small percentage of varied participants in the study developed pain after prolonged sitting, not a single group showed a propensity for neck pain (1). What does this mean? It means someone who held what is commonly thought as “good head posture” was just as likely to have neck pain as someone who kept their head forward, and vice-versa. Turns out, it's not the posture.


They didn’t stop there, because they did find factors that were associated with neck pain among the thousand plus participants. These included high stress levels, depressed mood and poor sleep. Other studies have shown similar findings in regards to neck pain (2,3), and back pain (4).


We also know posture and mood are closely related, as body language can be a behaviour used to enhance nonverbal communication (5,6). People who are sad may carry their head down and roll their shoulders forward. We’ve also seen how we can improve mood, confidence and even our pain threshold by holding a power pose (7). What we’re seeing here are a few indirect relationships between posture and pain modification, which may seem promising. Maybe we can affect pain with postural alterations? Unfortunately, I think this might be frequently taken out of context, especially since the “power pose” study has more recently been countered several times (8).


So maybe you agree at this point, and have moved on to “it’s not the posture that is bad, it’s how much time you spend in that posture”. Enter more science.


Is spending more time in a specific posture bad?


It is true that prolonged sitting time may factor into levels of discomfort, specifically when looking at the low back (9,10). We still cannot conclude that increased sitting time may cause “clinical” low back pain, meaning, a point where someone would need to see a professional for their back pain (9). Usually this pain or discomfort is felt during the prolonged period of sitting and self-resolves rapidly. What we can conclude from these studies, is that sitting for long periods of time may cause immediate low back discomfort, regardless of posture.


Here’s the problem, though: We still can’t say pain is caused by spending too much time in a specific posture. What we know from various studies, is people who deal with low back pain tend to change their posture more frequently than those without pain. It appears there might be a relationship between discomfort levels and changes in position over longer periods of time, which is thought to be a potential coping mechanism (11,12).


“Jeez, Dave, you’re killing me”, you must be thinking. So we can’t say that a specific posture can be the cause of pain; and we can’t say spending too much time in a specific posture is related to pain either, because people often change postures anyways. So all we can say is sitting time might be associated with increases in low back and neck discomfort, but not usually to the point where someone would need to go get help from a professional.


“So sitting isn’t the new smoking?”. It doesn’t seem that way, when it comes to back pain at least.


“Ok Dave, but what about the people who can’t sit in a certain position because it actually does bring on their pain?”


It is absolutely true that in some cases of low back or neck pain, certain movements and positions will be painful. For example, some people with low back pain are unable to round their back (bend forward) without recreating their pain. Or someone may have neck pain when looking down at their phone. So there are times where modification of our activities may be of benefit.


Painful behaviour can be learned (13). If, over time, you have developed back pain with forward bending and spend most of your time in a forward flexed position, then sure, you might be poking the bear. So this is a time when it might be best to temporarily use this postural option a little less. Remember, this doesn’t mean flexing or bending forward is bad, we just need a short break. We’ll eventually work our way back so this movement or position is achievable without pain.


Great, so now we’re making progress! There is a catch, though. I will let you take a moment’s pause to curse me out on my rampage against posture (I swear that wasn’t my intent here).


People with chronic low back and neck pain have a tendency to use what biomechanists call “muscle co-contraction”, otherwise known as muscle guarding or even more loosely - tightening the shit out of your muscles. No matter their posture, they tend to brace with their muscles far more than needed, and this doesn’t seem to change with postures (13,14,15). This is where focusing purely on seated posture may be futile during an acute bout of pain. Activity modification is probably a better option in this case (i.e. reduce sitting time altogether, incorporate some muscle relaxation exercises, keep the back moving, etc.).


Are there any studies that found an association between posture and pain?


I’d like to take this time to point out there have been studies in the past that have shown a relationship between posture and pain. However when looking closer at these studies, we find many holes. Let’s investigate by starting off with the big one. We’ve all heard someone reference this diagram from a paper by Hansraj (16).



Photo courtesy of Hansraj KK. 2014.


Before I share my thoughts, I will ask you a question: How many times in your life have you ever thought to yourself “gosh my head feels very heavy today”? Unless you were a brilliant baby, probably never? Our muscles and ligaments are very strong, and before phones, we were looking down at newspapers and books. Our postures may not have changed much over time, but other factors have.


This study has been cited over 200 times in the literature (that’s a good amount), but has never shown how they actually came about these numbers, and no one has been able to reproduce their findings since. To put this into context, I could tell you I figured out how to levitate, but not show you how. You just need to believe me. Not a good look.


Don’t get me wrong, I am not disputing that demands on our muscles, joints and ligaments would be higher when our head is further in front of us. This is basic physics, and I am NOT picking a fight with physics. But I will say it again: Our muscles and joints are very strong, and they adapt over time. We've already discovered that many people hold their bowling ball heads forward, and do not develop pain. Not only is the quality of the study in question, but so is its relevance, besides potentially scaring people into never looking down again.


I’d also like to point out the data from the studies that suggested associations between posture and neck pain. The results showed differences in head posture of approximately 2 degrees between those with and without pain. Yes, you read that correctly 2 degrees. You can’t spot this with the naked eye. It is also relevant to note the results are mixed as to whether forward head postures or upright head postures are associated with pain, because some studies say one is a cause and some say another (17).


Now it's my turn to pause for a little rant:


This showcases the importance of looking into claims before making them (I remind you, I used to fall into the group that didn't). Over the years we've been referencing conclusions of studies which say "bad posture causes neck pain" when in reality, the "bad posture" some of these studies found is in fact the typical "ideal posture" that is suggested all over the internet. We just aren't really looking into the details. There is no pattern to these conclusions, so I once again repeat, there is no association between posture and pain at this time.


I swear the "your head is 60lbs when it is 60 degrees forward" is the new "tryptophan is what makes you sleepy after eating turkey". EVERYONE says it without context. Ok, thank you for your patience - moving on.


Other clinical arguments such as “poor muscle endurance” or “poor motor control” being a cause of pain also have little to show for. We've already discovered that chronic muscle guarding/bracing/tightening is common in those with low back pain. Other studies have concluded the use of relaxation techniques are more beneficial for chronic low back pain than activation exercises (18).


If you’ve been working at your desk for 10 years, and all of a sudden started developing neck pain or back pain, it probably isn’t because your body’s muscles suddenly lost their endurance. There are other factors at play here. As for the argument of motor control, we don’t have much to support its relation to pain either (19).


Physical activity and chronic pain


So we’ve touched on how specific postures are not related to pain. We found that lower mood, lack of sleep and an increase in stress are related. One other factor we’ve yet to explore are physical activity levels.


A massive study (we’re talking close to 40,000 participants), was done out of Norway that followed people over the course of 11 years. What they found was individuals who participated in physical activity more frequently throughout the week had a decreased likelihood of developing chronic musculoskeletal conditions 11 years down the line compared to those who did not (20).


Physical activity is an important lifestyle factor, and those who live a more sedentary lifestyle have a higher risk of developing chronic musculoskeletal conditions (20). So perhaps including some additional physical activity throughout your week may be beneficial to reduce the likelihood of future aches and pains when at work.


So what can you do if you do have pain that you thought was related to posture?


Here are some recommendations to save you time, money, and potentially help with ongoing work-related discomfort.


  • All those fancy ergonomic devices you can buy? Hold off on those. There are many potential solutions to helping with your job or school work-related pain. It is best to try the easiest and cheapest solutions

  • The type of exercise you choose doesn’t seem to matter in neck or low back pain, so do what is most feasible for you (21, 22)

  • Try to work on improving sleep quality (expect a future article on this)

  • Find sources of stress, and troubleshoot ways to reduce these stressors

  • Try to increase physical activity levels away from work

  • Incorporate movement breaks during work, if this is enjoyable and possible for you


Conclusions


Generic postural advice is likely ineffective, especially as a preventative measure, as posture is not associated with pain. Management should be tackled from a case-by-case, person-centered approach. Using generic postural advice, and the term “bad posture” may be a classic example of the nocebo effect - meaning negative expectations can cause negative results. As we start avoiding certain postures deemed as “bad”, we have less movement variety and may become over-focused on our body, our discomfort or pain. From a “mechanical” perspective, movement variety is key. From a person-centered perspective, make sure to focus on all of the important factors listed above, and not just the mechanical ones. Remember, pain is complex.


So the next time someone tries to nag you on your posture, refer them to this article. Maybe they'll change their mind, just like I did mine.



References:


  1. Richards KV, Beales DJ, Smith AJ, O'Sullivan PB, Straker LM. Neck posture clusters and their association with biopsychosocial factors and neck pain in Australian adolescents. 2016.

  2. Damasceno GM, Ferreira AS, Nogueira LA, Reis FJ, Andrade IC, Meziat-Filho N. Text neck and neck pain in 18–21-year-old young adults. European Spine Journal. 2018 Jun 1;27(6):1249-54.

  3. Prins Y, Crous L, Louw QA. A systematic review of posture and psychosocial factors as contributors to upper quadrant musculoskeletal pain in children and adolescents. Physiotherapy theory and practice. 2008 Jan 1;24(4):221-42.

  4. O'Sullivan PB, Smith AJ, Beales DJ, Straker LM. Association of biopsychosocial factors with degree of slump in sitting posture and self-report of back pain in adolescents: a cross-sectional study. Physical therapy. 2011 Apr 1;91(4):470-83.

  5. Michalak J, Troje NF, Fischer J, Vollmar P, Heidenreich T, Schulte D. Embodiment of sadness and depression—gait patterns associated with dysphoric mood. Psychosomatic medicine. 2009 Jun 1;71(5):580-7.

  6. Nair S, Sagar M, Sollers III J, Consedine N, Broadbent E. Do slumped and upright postures affect stress responses? A randomized trial. Health Psychology. 2015 Jun;34(6):632.

  7. Carney DR, Cuddy AJ, Yap AJ. Power posing: Brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological science. 2010 Oct;21(10):1363-8.

  8. Cesario J, Jonas KJ, Carney DR. CRSP special issue on power poses: what was the point and what did we learn?. Comprehensive Results in Social Psychology. 2017;2(1):1-5.

  9. De Carvalho DE, de Luca K, Funabashi M, Breen A, Wong AY, Johansson MS, Ferreira ML, Swab M, Kawchuk GN, Adams J, Hartvigsen J. Association of exposures to seated postures with immediate increases in back pain: a systematic review of studies with objectively measured sitting time. Journal of Manipulative and Physiological Therapeutics. 2020 Feb 17.

  10. Leban B, Arippa F, Fancello G, Fadda P, Pau M. Analysis of Discomfort During a 4-Hour Shift in Quay Crane Operators Objectively Assessed Through In-Chair Movements. InCongress of the International Ergonomics Association 2018 Aug 26 (pp. 90-100). Springer, Cham.

  11. Søndergaard KH, Olesen CG, Søndergaard EK, De Zee M, Madeleine P. The variability and complexity of sitting postural control are associated with discomfort. Journal of Biomechanics. 2010 Jul 20;43(10):1997-2001.

  12. Dreischarf M, Pries E, Bashkuev M, Putzier M, Schmidt H. 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?. Journal of biomechanics. 2016 Mar 21;49(5):638-44.

  13. Hodges P, van den Hoorn W, Dawson A, Cholewicki J. Changes in the mechanical properties of the trunk in low back pain may be associated with recurrence. Journal of biomechanics. 2009 Jan 5;42(1):61-6.

  14. Jones SL, Henry SM, Raasch CC, Hitt JR, Bunn JY. Individuals with non-specific low back pain use a trunk stiffening strategy to maintain upright posture. Journal of Electromyography and Kinesiology. 2012 Feb 1;22(1):13-20.

  15. Schinkel-Ivy A, Nairn BC, Drake JD. Investigation of trunk muscle co-contraction and its association with low back pain development during prolonged sitting. Journal of Electromyography and Kinesiology. 2013 Aug 1;23(4):778-86.

  16. Hansraj KK. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 2014 Nov;25(25):277-9.

  17. Oliveira AC, Silva AG. Neck muscle endurance and head posture: a comparison between adolescents with and without neck pain. Manual therapy. 2016 Apr 1;22:62-7.

  18. Wong AY, Parent EC, Prasad N, Huang C, Chan KM, Kawchuk GN. Does experimental low back pain change posteroanterior lumbar spinal stiffness and trunk muscle activity? A randomized crossover study. Clinical Biomechanics. 2016 May 1;34:45-52.

  19. de Zoete RM, Osmotherly PG, Rivett DA, Snodgrass SJ. Cervical Sensorimotor Control Does Not Change Over Time and Is Not Related to Chronic Idiopathic Neck Pain Characteristics: A 6-Month Longitudinal Observational Study. Physical therapy. 2020 Feb 7;100(2):268-82.

  20. Holth HS, Werpen HK, Zwart JA, Hagen K. Physical inactivity is associated with chronic musculoskeletal complaints 11 years later: results from the Nord-Trøndelag Health Study. BMC musculoskeletal disorders. 2008 Dec 1;9(1):159.

  21. Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain. Physical therapy. 2007 Apr 1;87(4):408-17.

  22. Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC musculoskeletal disorders. 2014 Dec 1;15(1):416.