Posture & Back Pain – Does it Matter?
‘Stand up straight!’
How many of us have heard this statement and wondered why? Posture has long been associated with notions of health and well-being. Before posture was blamed for causing poor health and physical pain – it had a different role altogether. Posture is originally a French word that has its origin in classical Latin ‘Positura’ – referred to the “the relative disposition of the various parts of something; esp. the position and carriage of the limbs or the body as a whole, often as indicating a particular quality, feeling, etc.; an attitude, a pose” (5).
The first idealised notions of good posture arise from 16th century military journals describing “a particular position of a weapon, or a method of wielding it, in drill or battle” (5). The ideal or rest position comes to be “standing at attention” with a more or less rigid spine, tucked-in chin and feet clearly positioned under the head, back upright but yet not rigidly aligned with the rest of the body. The development and representation of military drill formation became the fertile ground for the idealised erect standing position in our culture today (5).
Idealised military notions of posture then found their way into civilian life in the 18th and 19th centuries with the Leipzig anatomist Christian Wilhelm Braune and his student Otto Fischer dropping the plumb line along the now acceptable rigid posture of “standing at attention,” bringing the study of military posture into the medical literature (5). A century later we see the first instances of ‘functional exercises’ focused on improving posture. During the reign of the last Emperor of Germany, Kaiser Wilhelm II, American body culturist Elizabeth Marguerite de Varel Mensendieck (c.1866–1959) was hired to improve the posture of his courtiers (5). Elizabeth describes her ideal posture:
“When the human animal stands properly erect, an imaginary line should cut the nose, chin, breastbone and crotch. Another imaginary line should drop from the mastoid, in front of the shoulder joint, through the elbow and little finger (palm turned to the rear), side of knee and ankle. This is achieved by standing with feet together, shoulders held back, abdomen tucked in, buttocks clenched” (5)
Fast forward to the 20th century and ideal notions of posture had now spread wide into the popular culture through efforts of organisations like the American Posture League – see the picture below (5). 
During this time, functional definitions of posture came to dominate the debate around posture, at least within medicine, although little attention is given to its origin. The Posture Committee of American Academy of Orthopaedic Surgeons in 1947 defined posture as “the relative arrangement of the parts of the body,” making a distinction between good posture: “the state of muscular and skeletal balance which protects the supporting structures of the body against injury or progressive deformity irrespective of the attitude in which these structures are working or resting” and poor posture as “a faulty relationship of the various parts of the body which produce increased strain on the supporting structures and in which there is less efficient balance of the body over its base of support.” (pg 72 – excerpt from “Stand Up Straight”: Notes Toward a History of Posture 5).
As science has taken more and more of a role in human’s quest for knowledge, we have found little evidence to support these long-held notions between posture and pain/dysfunction, particularly low back pain (2). Whilst low back pain remains a very common and costly musculoskeletal disorder, it is a complex symptom with a multitude of causal factors (1,7). And yet, through hundreds of years of socio-cultural conditioning and well-intentioned attempts at medicalising good posture – we see it commonly blamed as a primary source for peoples back pain. Low back pain is still often ascribed to relatively “normal” variations and asymmetries in peoples posture by health practitioners, despite the lack of strong evidence to support such a claim (2).
Image source: Ben Cormack Cor-Kinetic
The reality of back pain is far more complex. We now realise that low back pain arises through a complex interaction of people’s biological, psychological and social circumstances (2). Meaning that a person’s experience of back pain is not well understood solely as a result of a degenerative spine or disc bulge, but more by a combination of stressors, be they physical, psychological or social (1). And the more these stressors create a perception of danger to the body (consciously or unconsciously) – the more likely we are to experience pain (4).
Yet if we see someone lifting a heavy object with a curved spine – most of us shudder and express concern for their back. Loading or lifting a curved spine has been discouraged by Physiotherapists, Chiropractors and Doctors for decades. The premise being, that loading a flexed spine tends to degrade the health of the intervertebral discs, and disc degeneration, particularly with disc space narrowing is associated with pain (1). Even sitting in recent years has been discouraged – as it has been shown to increase risk of poor health outcomes and induce higher loading on the intervertebral discs (2). Since childhood we have been urged to not slouch and sit up straight whilst at school lest we want to end up looking like Quasimodo from the Hunchback of Notre Dame (see picture below).
However, when asking the experts – there is little consensus on the best sitting posture (1). Slouched sitting has even been shown to increase intervertebral disk height and hydration (3). But still we find an increased emphasis on adopting “neutral” lumbar spine postures, to avoid potentially painful end-range positions (1). The avoidance of such postures may not be only unavoidable but unhelpful for people in pain as we increase the perception of vulnerability and postural vigilance that is shown to associated with further pain (1,4). The topic of spinal posture and safety of neutral vs end range positions is extensive – for those wanting a more in-depth explanation I suggest you read this blog by Greg Lehman: RECONCILING SPINAL FLEXION AND PAIN: WE ARE ALL DOOMED TO FAILURE BUT PERHAPS IT DOESN’T MATTER
While there is no clear evidence that prolonged sitting in isolation is a significant risk factor for developing low back pain, combined exposure to prolonged sitting and awkward postures may increase the risk of developing it, likely due to an increased amalgamative stress that increases the likelihood of pain (1,4). But considering the large amount of time spent sitting in modern society, assuming seated spinal postures that are non-provocative is likely to be helpful for those experiencing lower back pain (2).
At the end of the day, we are far more adaptable and resilient than we give ourselves credit for. Our hang up on posture, like most of our cultural hang ups, is one of inter-generational conditioning. Handed down from military handbooks in the 16th century, to aesthetically concerned royals and doctors of the 18th and 19th centuries, passed through to us through overly medicalised posture zealots of the 20th and 21st centuries.
We once thought bloodletting was a good medical treatment for all types of maladies, but it turned out deadly in the light of scientific experimentation. Like bloodletting, notions of ideal posture have been handed down as gospel for pain relief, however, end up not well supported in the light of science. Next time you see a friend slouching at the desk or bending over awkwardly to pick something up – don’t worry, they’ll be okay.
Oliver Crossley
(APAM) POGO Physiotherapist
Book an appointment with Oliver here
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References
- O’Sullivan, Kieran, Peter O’Sullivan, Leonard O’Sullivan, and Wim Dankaerts. “What do physiotherapists consider to be the best sitting spinal posture?.” Manual therapy17, no. 5 (2012): 432-437
- Slater, Diane, Vasileios Korakakis, Peter O’Sullivan, David Nolan, and Kieran O’Sullivan. ““Sit Up Straight”: Time to Re-evaluate.” journal of orthopaedic & sports physical therapy49, no. 8 (2019): 562-564
- Pape, John L., Jean-Michel Brismée, Phillip S. Sizer, Omer C. Matthijs, Kevin L. Browne, Birendra M. Dewan, and Stéphane Sobczak. “Increased spinal height using propped slouched sitting postures: Innovative ways to rehydrate intervertebral discs.” Applied ergonomics66 (2018): 9-17
- Butler, D., and G. Moseley. “Explain pain supercharged.” Adelaide City West(2017).
- Gilman, Sander L. ““Stand Up Straight”: Notes Toward a History of Posture.” Journal of Medical Humanities35, no. 1 (2014): 57-83.
