This week I would like to discuss sitting posture and its relevance to pain.

Story Time

Let us begin with a quick story we have probably all heard of or lived. Perhaps at some point, Mom, acting in our best interest advises us to ‘sit up straight’ in an effort to protect us from becoming permanently fixed or contorted in some awkward posture. This advice usually comes when she catches us taking a deep forward lean into a TV or when resting our head in our hand while eating dinner at the table. Mom probably believes to some degree that this position is not good for us and could lead to some negative future consequence. Now Mom usually knows best, but does she have scientific grounds for this belief? Should we always be seated in an upright posture to prevent some consequence from occurring? More specifically, should we always be sitting with good posture to prevent new onset pain or if something starts to hurt should we make efforts to modify our posture? Also, are there any potential harms associated with postural advice?

What posture are you assuming? Will there be a permanent consequence to this?

The Public Perception

The perception of the public at large appears to believe “bad posture” will lead to pain which has been reinforced by media and well intentioned health care practitioners (HCP). Consumer market products including braces, corsets, clothing lines, and taping techniques try to bring great awareness to the importance of having good posture all in an effort to prevent or alleviate pain. HCP’s or field experts do the same by providing education as a regular part of their treatment programs and often blame posture as a driving factor as to why something hurts. This advice delivered by HCP’s usually revolves around the idea that we should assume ‘optimal’ or ‘good’ postures. Since we're on the topic what is considered to be good posture? It appears the general consensus is sitting up straight, shoulders pulled back, and the chin tucked in. To further explain why assuming this posture is important, a patient may receive a lesson in pathoanatomy and biomechanics (i.e. upper-lower crossed syndromes and tissue creep) and provided with a list of muscles that are long, short, or weak and how postural changes can unload these structures. Now sometimes postural correction can work, heck, anything can work for some patients, but with our current understandings of pain science and nervous system sensitivity, do we need to be overly concerned about correcting seated posture? Furthermore is the advice of finding an ‘optimal’ posture grounded in science?

Figure 2: Reversal of the lumbar lordosis, severe thoracic kyphosis, protracted shoulder girdle and a forward head posture - the evidence would probably suggest this cat is going to hurt right?

Evidence: head, shoulders, scaps and back

What does the evidence have to say about posture and pain? Beginning at the shoulder, in a recent systematic review published in the BJSM from Ratcliffe et al, authors investigated whether scapular orientation (and kinematics) in subjects with subacromial impingement syndrome differed compared to asymptomatic controls1. Authors were unable to find a link between scapular position and shoulder pain and suggested that “deviation from a ‘normal’ scapular position may not be contributory to SIS but part of normal variations.” This reminds me of some of research and talk around gait - are walking patterns similar in the way the scapula rests, everyone is different and scapular position is simply a unique signature of that person. Getting back to the study, what this may suggest is that the dreaded protracted shoulder girdle (i.e. anterior tilt of the scapula and anterior humeral head) posture may not lead to pain. If this is true, do patients always need to sit back and retract those shoulders?

Perhaps a thoracic kyphosis and head forward posture will predict who gets pain? A recent study looked at 1100 asymptomatic adolescents and took pictures of their sitting posture. Based on the pictures, subjects were then clustered into one of four postural groups: upright, intermediate, slumped thorax/forward head and erect thorax/forward head postures2. After some sub-group analysis there was no significant association found between any of these postures on neck pain and headache. Interestingly, what authors did find was that those subjects with the slumped thorax/forward head posture was a strong association with depression. Psychosocial factors time and time again have been shown to predict who may experience pain or go on to have a protracted recovery. So perhaps instead of blaming posture for pain, we see one’s general posture as a window or insight into the general well-being of the person in front of us.

Well if shoulder, thoracic, and head forward posture does not predict who gets pain sitting for long periods of time has got to increase the risk of pain right? Consider this study: about 1700 workers were followed for 15 years and authors tracked the amount occupational sitting and its relationship with various health-related outcomes, with one being musculoskeletal pain3. Authors concluded that those who sit at work for four or more hours per week were at decreased risk for chronic upper extremity pain compared to workers with low occupational sitting time (0–3 hours per week)3. As a side note, it was also concluded that occupational sitting did not increase risk of mental health problems, overweight, hypertension or hypercholesterolemia compared to workers with stable occupational non sitting 3. Wow, can we truthfully say sitting is the new smoking!?! More research is obviously required to answer that one.

People in pain change their posture right…?

One more point, some may argue that posture changes as a function of pain, but even this idea is called into question. Consider this classic RCT from Jull et al. who assigned subjects with signs and symptoms of cervicogenic headaches to one of four groups: manipulative therapy, exercise therapy, combined therapy, and a control group4. In this study, one of the outcomes was a measurement of forward head angle derived from a photograph taken at baseline and at 3, 6, and 12 month follow up. At each time point, there was no change in the photographic measurement of forward head postural angle in any group. Also interesting to note, there were a few similarities across each group: 1) none of the subjects in the intervention groups were given postural education and (2) these subjects were also exposed to novel inputs likely delivered by confident therapists who strongly believed in their treatments. That sounds like recipe for success!

At this point you may be thinking that it would be naive to completely ignore sitting posture and I would have to agree. It still may be useful, as we learned above posture may lend insight into an underlying psychosocial issue which is strongly associated with pain. Temporary postural changes during the symptom modification procedure (SMP) may also help to desensitize some movement or finding a new posture may be enough to create a novel input to the system and allow for better movement to occur. Although the utility of SMP has been debated recently by Adam Meakins and Greg Lehman.

Advising someone to stay in posture they don’t normally stay in all day every day...what's the harm?

What if we ignored the evidence and provided postural education for everyone? What’s the harm? If you have an opportunity, listen to expert physiotherapist Peter O’Sullivan speak on BJSM’s podcast here where he discusses two clinical cases and highlights the issue of core stability and low back pain. As a brief background, many patients with low back pain are often told their symptoms are due to weak core muscles. What follows is advice and exercises to improve core strength. However, part of what is discussed in this podcast is some of the evidence and anecdotes behind increased trunk muscle activity and rigidity strategies seen in some low back pain patients and the potential harm done by encouraging more activation of these already overactive core muscles. So if there are already overactive muscles working to protect an area is it possible to worsen one’s condition by providing more activation exercises? Perhaps this is possible. With this in mind, do we want all our patients to sit seated with a flat back, core engaged, scapulas pulled back and chin pulled in all day, part of the day, every day? Maybe not.

Words that heal and words that harm

Consider the following two scenarios:

Scenario 1: Well Ms. Jones, because you sit too much, your shoulders are constantly rolled forward, and the hip flexors have become short and tight, causing your back is being pulled into excessive lumbar lordosis resulting in pain. Also, because of the sitting your core and glutes could be weak and haven’t you heard about the saying “sitting is the new smoking?” But we can work on all these things, but first we need to improve your posture and second get you more active.

Scenario 2: Well Ms. Jones, your back could be singing to you a bit more lately because it’s trying to get your attention. Perhaps we can start with a few simple exercises to get your back and hips moving a little better and go from there. Although you did mention a recent increase in stress at work and have not been sleeping well. These are two important things we should look trying to change since they too can influence your symptoms.

What story would you like to hear? Was one more threatening than another? We need to provide honest and evidence informed answers to our patient’s. Don’t forget that words we use can harm too.

These postures don’t seem to be bothering this baby.

Take Homes

Back to the clinic, if we see a wonky scapula, thoracic kyphosis, flatback or chin poking forward not to worry, finding that perfect plumb-line posture may not be as important as we (and mom) once thought. In fact, over-correcting posture may do more harm than good. Speaking more generally, there are already enough pressures in society, many of which have us creating constant internal dialogue of what we should look like, how we should move or be. Does everyone need to be told they have gray hairs, wrinkles on their face, or a need a new pair jeans? How does that make us feel? Similarly, this does happen at the clinic level. Is there any harm in pointing out a slumped back, a forward shoulder and ‘tight’ hip flexor? What about highlighting degenerative changes, calcium deposits, and muscle tears seen on scans? Meh, for many patients no harm is done, but some hang onto to those explanations as reason for their pain and may continue to use well-intentioned advice not relevant to the problem that may actually prolong their symptoms. What do I suggest we do? First be guided by the evidence, postural corrections may not be necessary. Second, let's start making patients feeling good about themselves during clinical experience. How? Use positive language, point out the good and highlight the plan to reach their goals. Again, focus on the good, not the faults, and leverage what patients are already doing if at all possible. Finally, as per usual, continue to educate, empower, encourage.

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References

Ratcliffe et al. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. BJSM. 2014.
Richards et al. Well characterised neck posture is not related to neck pain in adolescents in a large community-based sample. Musculoskeletal Science and Practice. 2016.
Picavet et al. The Relation between Occupational Sitting and Mental, Cardiometabolic, and Musculoskeletal Health over a Period of 15 Years – The Doetinchem Cohort Study. PLOS One. 2016.
Jull et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002.

Posture and Pain. Are they Connected or Confounded?