Pain Science (Part 3/4): Does “Bad” Posture Cause Pain?

Have you ever been told to sit up straight? That your posture is bad? Maybe even a credible source, like a healthcare provider, has told you that your posture or the way you move is bad and will lead to pain later in life.

The belief that certain postures or movements are bad is common within Western culture, and one which certainly makes sense at face value. The underlying theory is that “bad” postures or movement leads to tissue damage which subsequently leads to pain. In some circles this is referred to as the kinesiopathic model of pain and is one which many healthcare practitioners, like physical therapists, have subscribed to. Now, we know from part I (see *here*) that this is an insufficient explanatory model, but is there anything to it?… Can posture be bad and cause pain? Let’s break it down and check the evidence

There is evidence linking certain postures to tissue degeneration

Several authors have published research examining the relationship between posture/ movement patterns and tissue degeneration. Sharma in 2010 conducted a 30-month longitudinal study on knee alignment and osteoarthritis (OA) and found an increased risk of OA development with varus (bow-legged) alignment as well as increased risk of OA progression with either varus or valgus (knock-kneed) alignment.¹ Yamamoto in 2015 examined the relationship between posture and rotator cuff tears in 525 subjects and found a significantly higher incidence of rotator cuff tears in individuals with posture that deviated significantly from the “ideal” plumb line posture (aka “bad” posture.)²

But is this enough to be concerned & say these postures are bad?

There are two major problems with designating certain postures as bad based on data like this. First, we can only infer a correlative relationship between posture and degeneration from these studies, not causation. Simply identifying this correlation doesn’t tell us that these postures are the independent variable leading to pain – maybe they simply correlate with another factor which could play a greater role like occupation, or maybe the postures were adopted because they place less stress on the degenerated tissue (like a flexed, bent forward spine placing less stress on a facet joint.) We just frankly don’t know, but my personal bias is it’s a mixture of all the above. Second, even if posture does have a causative relationship with tissue degeneration at what point does it become enough to care? We know tissue degeneration, while sounding scary, does not predictably lead to pain (see *here*) or issues so, outside of select conditions, (to be expanded on in a future post) this degeneration isn’t really concerning.

It’s possible that posture causes pain, just with a different mechanism leading to pain, right?

Not quite. In a 2016 systematic review Barrett examined the relationship between some of the poor postures examined by Yamamoto (thoracic kyphosis) to shoulder pain and found no relationship.³ Richards in 2016 examined the head/neck and upper back posture of 1,108, 17-year-old subjects and found no link between any posture – including “bad” postures — and neck pain.⁴ Similarly, Dolphens in 2012 examined standing posture in 1,196 adolescents and found a very slight, but also poor relationship between posture and pain.⁵ Further, in a 2008 review Christensen found no relationship at all between standing posture and pain.⁶ So it’s not that the mechanism is different… the relationship just isn’t there.               

But these are mostly just kids! They haven’t been in the bad postures long enough!

This appears to be a good counter argument at first, but it doesn’t hold up. Villumsen in 2015 examined the relationship between time spent in a bent over position and pain in a sample of 198 blue collar workers with an average age of ~45.⁷ He found that workers who spent a longer duration in a forward bend (even a large, 90-degree bend) had less pain than workers who spent less time bent over. This is the total opposite of what common knowledge dictates! However, under the biopsychosocial model & concept of sensitivity it makes sense. Spending an extended duration in a position allows the body and nervous system to adapt to the position and, as it becomes accustomed to it, see it as non-threatening.

Okay fine… but maybe the people with pain are just moving in a way that excessively stresses the damaged tissue & those without have adapted!

I was initially biased in favor of this argument, but it also doesn’t hold up. Thoreson in 2017 looked at elite skiiers and found that while they were significantly more likely to have spinal degenerative findings, they were no more likely to have had back pain than non-athletic controls even while heavily loading a “degenerated” spine in their sport.⁸ This again goes back to the idea of sensitivity – the body has adapted and become accustomed to the loading.

But that’s just short term! They will pay for it later!

Athletes competing in any sport, regardless of the specific demand required, are more likely to experience back pain than non-athletes.⁹ Additionally, athletes competing in sports which heavily load the spine like rowing and skiing do typically have an even higher likelihood of experiencing pain as well as a greater pain intensity.⁹ However, as this is seen in a variety of athletes with varying sport demands (both load and movement) the relationship may be best explained through volume of spinal loading more so than any specific movement patterns or postures. This is supported by the fact that at 10 year follow up skiiers and rowers (who were constantly moving in a “bad” way and heavily loading the spine) were no more likely to have pain than non-athletes — showing it is not true that you will pay later for moving “badly” and placing a high demand on your spine.¹⁰

So are you saying posture and movement patterns don’t matter?

Nope, I’m not!

Posture and movement patterns do matter in certain circumstances, including pain. However, based upon what we know from the literature we should not worry about our daily postures or consider any posture inherently “bad.” I’ll expand heavily on this in the final post of this series.

Quick Recap:

• Posture and movement patterns have a relationship to tissue degeneration, but we can’t say it’s causative
• There is no significant link between “bad” posture/movement patterns and pain, even in the presence of significant tissue damage
• High load, intense athletic activities do not appear to increase risk for low back pain later in life
• No posture is inherently “bad” for you

 

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Thanks for reading,

~Adam

 

References:

1. Sharma L, Song J, Dunlop D, et al. Varus and Valgus Alignment and Incident and Progressive Knee Osteoarthritis. Annals of the rheumatic diseases. 2010;69(11):1940-1945. doi:10.1136/ard.2010.129742. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2994600/)
2. Yamamoto A, Takagishi K, Kobayashi T, et al. The impact of faulty posture on rotator cuff tears with and without symptoms. J Shoulder Elbow Surg. 2015;24(3):446-52. (https://www.ncbi.nlm.nih.gov/pubmed/25441565)
3. Barrett E, O’keeffe M, O’sullivan K, Lewis J, Mccreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016;26:38-46. (https://www.ncbi.nlm.nih.gov/pubmed/27475532)
4. 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. Phys Ther. 2016;96(10):1576-1587. (https://www.ncbi.nlm.nih.gov/pubmed/27174256)
5. Dolphens M, Cagnie B, Coorevits P, et al. Sagittal standing posture and its association with spinal pain: a school-based epidemiological study of 1196 Flemish adolescents before age at peak height velocity. Spine. 2012;37(19):1657-66. (https://www.ncbi.nlm.nih.gov/pubmed/22108378)
6. Christensen ST, Hartvigsen J. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manipulative Physiol Ther. 2008;31(9):690-714. (https://www.ncbi.nlm.nih.gov/pubmed/19028253)
7. Villumsen M, Samani A, Jørgensen MB, Gupta N, Madeleine P, Holtermann A. Are forward bending of the trunk and low back pain associated among Danish blue-collar workers? A cross-sectional field study based on objective measures. Ergonomics. 2015;58(2):246-58. (https://www.ncbi.nlm.nih.gov/pubmed/25374330)
8. Thoreson O, Kovac P, Swärd A, Agnvall C, Todd C, Baranto A. Back pain and MRI changes in the thoraco-lumbar spine of young elite Mogul skiers. Scand J Med Sci Sports. 2017;27(9):983-989. (https://www.ncbi.nlm.nih.gov/pubmed/27367529)
9. Bahr R, Andersen SO, Løken S, Fossan B, Hansen T, Holme I. Low back pain among endurance athletes with and without specific back loading–a cross-sectional survey of cross-country skiers, rowers, orienteerers, and nonathletic controls. Spine. 2004;29(4):449-54. (https://www.ncbi.nlm.nih.gov/pubmed/15094542)
10. Foss IS, Holme I, Bahr R. The prevalence of low back pain among former elite cross-country skiers, rowers, orienteerers, and nonathletes: a 10-year cohort study. Am J Sports Med. 2012;40(11):2610-6. (https://www.ncbi.nlm.nih.gov/pubmed/22972850)