The Posture Boogeyman
Delving into the perceived evils of 'bad' posture
When it comes to pain, particularly pain in the neck or back, the word posture usually isn't far behind. It is something which has been blamed for a lot of ills, and seems to carry a lot of weight on its (or your) shoulders.
Today I want to take a look at posture, what it means, and whether it really has that much power over you and how you feel.
You can all hear it now.
The voice of you mother when you were a child coming from over your shoulder, admonishing you for the reprehensible sin of your terrible posture.
If you were to keep going with your wicked ways you would end up like Gran, hunched and gnarled, with all manner of nasty problems as a result.
I'm probably being a tad dramatic, but it probably actually felt that way when you were a kid.
But is having 'bad' posture really that bad?
And what even is bad posture?
Defining the indefinable
The biggest problem with trying to define what bad posture is, is that we have a great deal of difficulty defining what good posture is.
If we ask the Oxford dictionary, it would say that posture is "The position in which someone holds their body when standing or sitting"(1). Fair enough, but what about a definition for good posture. Well, there isn't one. Nor one for bad posture either.
In fact, if you google posture, there are thousands (yes, thousands) of websites talking about the benefits of good posture and the evils of bad (google actually returned 87,100,000 results for the word posture alone. I didn't read them all, in case you were wondering).
So it seems like a lot of people seem to know all about good and bad posture.
Well, not really.
Many of those sites don't actually have a definition of what 'good' or 'normal' posture is. I looked at the first 20 results and found that while they pretty much gave the definition I gave you above for posture, none of them had definition of what good posture was, despite saying how important it was. Some tried, but the definitions were so wide and varied it would be difficult to come up with any sort of consensus on the matter
There is talk of efficient postures and alignment of bones, having correct curves and balanced muscles, but there is a fair bit of ambiguity on what 'normal' posture is.
And you know why that is?
Because there's no such thing.
It's a bit of a human obsession to categorise things as normal or abnormal. The fact of the matter is, there is so much variation between humans that identifying what is normal is quite difficult, and depends on so many factors.
There is the common belief that "poor" posture is due to weak muscles in one area and tight muscles in another. So the focus of managing this is to strengthen the weak, and stretch the tight. I would hazard a guess that no matter how much people who have been instructed to do this, they always find they struggle to maintain a good posture. Despite the somewhat reasonable explanation, there has been next to no evidence ever provided that this actually has any impact.
Targeting specific muscles with specific strengthening or stretching doesn't work, not any better than general movement and exercise does.
Can we have poor posture?
Though it doesn't really have anything to do with your sitting or standing position.
Paul Ingraham, a science writer and massage therapist, says it best when he states:
"poor posture is an unnecessary and problematic pattern of physical responses to postural challenges"(2)
You'll notice this has nothing to do with spinal alignment or positioning. He talks about posture being a response to stress and challenges. It is more in reference to movement.
It is talking about our response to various positions and movements. Most issues from "poor" posture are minor and self-limiting. It also doesn't focus on how someone looks standing still.
Bit stiff from sitting hunched for a few hours? Stand up and move around
Fatigued or achey from standing up straight for a long time? Sit down, take a break.
These are things we tend to do naturally, because we don't like discomfort.
Plumb in front
Often good posture is discussed in reference to a Plumb Line, where a straight line is drawn from the top of your head to the ground. Theoretically, this line is supposed to run through your ear lobe, shoulder then the outer point of your hip knee and ankle. If this happens, you have an ideal and upright posture, if it doesn't you need to adjust so it does.
It looks a bit like this below, taken from a book called Muscles: Testing And Function, With Posture And Pain, which is a bit of a staple of physiotherapy training.
As you can see, it shows an "Ideal Posture" along with a few less than ideal ones. The problem with this is, how your posture affects you has very little to do with what you look like standing still. Personally, I probably look something like the skeleton 'B' in the picture, but I am also quite hypermobile, so I rarely spend a lot of time in that position and can move and straighten quite easily.
Posture ≠ Pain
For the record:
Posture does not equal pain.
Nobody out there has pain because their posture is bad. Plain and simple.
Having a curved upper back does not automatically mean you will have pain. A study from 1994 looking at 610 women who all have severe kyphosis (hunching of the upper back) found kyphotic women had no greater back pain, disability caused by back problems, or poorer health(4).
Even those with severe kyphosis.
There are examples of people who have what most would see as terrible posture, and little or no pain. Conversely, it's probably even more common to see people with what we would see as perfectly normal posture who have ongoing neck or back pain.
There has always been a focus on adolescents and slouching, and in recent years there has been much ado about people having increased neck problems because of all the mobile phone use. Yet there is very minimal evidence which suggests either of these things have actually caused a massive increase in pain(5).
Sure there may be a few more people who have a slouch or forward head posture because of this, but I'm talking about it's relation to pain.
As I've said before, pain is incredibly complex, with many factors influencing it. With this in mind, it wouldn't make sense for pain to simply be as a result of having your spine in a certain position (with it is designed to be able to do).
So does that mean posture is completely irrelevant?
Whoa, slow down there. Let's not get too ahead of ourselves.
I've mentioned that there is a poor correlation between posture and pain, but that doesn't mean that posture isn't important to a certain degree. It's just not as important as people think it is.
When it comes to posture my focus is less on how you look when you are in a particular position, and more on how long you hold those positions for, and how well you can move out of them.
If you are at work and you sit or stand for a long period in a bit of an awkward position, you are more than likely to suffer with some postural strain. This is the discomfort you feel which is essentially your body telling you to change your position. It could be because your muscles are becoming fatigued, or a certain area is getting less blood flow.
I'm sure we've all felt that.
But if I was to get you to sit or stand with "perfect" posture for most of the day without moving, what's the chances you might still experience some of this postural strain?
Obviously, some positions are going to result in this strain more than others. Standing bent over is more likely to fatigue you quicker than standing upright and relaxed, walking with a heavy bag over one shoulder is likely to require more effort than walking with a well adjusted backpack.
The key to avoid postural discomfort often isn't having perfect posture, its frequent movement. Changing positioning regularly makes a big difference. As is often said:
"Your best posture is your next posture"
Most of us do this instinctively anyway. We shift and move as we get uncomfortable in different positions. It becomes more of an issue if we are at work or performing a task which requires us to be in a certain position for a long period. In that case, we need to be more consciously aware of it.
Improving the efficiency of positioning and postural movement can help to reduce any sensitivity or strain you might be experiencing. So that's why looking at ergonomically set up desks, or chairs, and looking at manual handling isn't a waste of time. It's just not the be all and end all.
The big problem is, once again, what is ideal?
Take this image below, which is one of many different representations of the ideal sitting posture.
So which of these is the best position?
The answer: None of them. Or all of them.
What I mean by that is, adopting all of those sitting positions over the course of the work days is going to be more beneficial.
Sit forward, sit back, sit upright, slouch, lean to one side, or lean on the desk. Do all of them. Just change positions regularly. People will find different levels of comfort in different positions because we are all different.
Good posture is dynamic, it is about movement and change(2).
But I don't like my posture!
I would say there is little doubt that people like having "good" posture. Aesthetically it tends to be more pleasing, and people tend to feel better. We even talk about people who have confidence and purpose as walking with "their head held high, shoulders back and chest out".
We see these people as important because they look it.
There is a bit of a question mark over whether we can even really change posture. Your posture, or the way you hold yourself, is less about structure and more about your spinal reflexes with input from your nervous system and brain. And while we can consciously change our posture, most of it happens unconsciously(2).
When we stop thinking, we tend to revert back to our regular posture.
So what does that all mean?
The key point of all of this is that the majority of people don't experience pain because they have poor posture. People can experience increased strain and fatigue from holding poor positions for long periods, but the length of time tends to be more important than the position, and that is often easily fixed.
Ergonomics can be important, but not as important as looking at you and the way you hold yourself. Performing movement and even strength exercises can be helpful, not because structures are tight or weak, but because they need to move. It might also improve your endurance for holding said posture.
Telling someone their pain will improve if they spend every minute of every day in a "perfect" position, both in sitting and standing (and occasionally when your sleeping, like we have any conscious control over that!), is just plain wrong.
So stress less about your posture and focus more on your movement.
After all, motion is lotion.
Take Away points:
There is no one "correct" posture;
"Poor" posture is more about sustained positioning rather than good alignment;
Posture and pain are poorly correlated;
Posture is not irrelevant, it's just not as important as many think;
Strategies for movement and change of position are just as important, if not more, than ergonomics.
Oxford Dictionaries, 2017, Good Posture, Oxford University Press, https://en.oxforddictionaries.com/definition/posture, accessed 23/10/17;
Ingraham, P, 2017, Does Posture Correction Matter?, Pain Science, https://www.painscience.com/articles/posture.php, accessed 23 August 2017;
Kendall, EP, McCreary, EK, Provance, PG, Rodgers, MM, and Romani, WA, 2005, Muscles: Testing And Function, With Posture And Pain, Lippincott Williams and Wilkins, 5th Ed;
Ettinger B, Black DM, Palermo L, Nevitt MC, Melnikoff S, Cummings SR. Kyphosis in older women and its relation to back pain, disability and osteopenia: the study of osteoporotic fractures. Osteoporos Int. 1994 Jan;4(1):55–60. PubMed #8148573;
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. Phys Ther. 2011 Feb. PubMed #21350031.