POSTURE: An important, yet underestimated tool
by: Amanda Dalcourt, B.Sc.(PT), Cert MDT, Dip MDT
Posture – so basic and yet so important. The importance of this tool in clinical practice is underestimated and thus, underused. During the nine-week clinical component of the McKenzie Institute International’s Diploma program, I learned the importance of posture as an essential tool in the diagnosis and treatment of both acute and chronic musculo-skeletal conditions. Seeing the numerous positive responses to such a simple intervention reinforced the importance of posture as a necessary clinical tool. Many times, posture was all that was needed to affect a change in a patient’s condition. There was no need for any hands-on techniques. Simply teaching the patient about posture and increasing postural awareness was enough to help him/her control pain and enjoy success with treatment. Posture has been defined as “a position or attitude of the body, the relative arrangement of body parts for a specific activity, or a characteristic manner of bearing one’s body”.2 In this paper, the importance of sitting posture as a clinical tool will be shown in two ways: diagnostically and therapeutically. Through these examples, it will become apparent that the significance of posture should be considered as a foundation for many patients that we treat.
The ability to use posture as a diagnostic tool begins with the subjective interview. Neck position has been shown to be related to the position of the lumbar spine and pelvis,1 therefore, this principle should be equally applied to patients with low back pain and with neck/thoracic pain. During the history taking, with the patient sitting unsupported, the response to that particular sitting posture can be captured. Fidgeting by the patient may be an indication of pain or discomfort, and this may be of some diagnostic value. It also affords the clinician an opportunity to take advantage of a very important educational moment. Modifying sitting posture to obtain a more comfortable resting position can provide important functional information, which can be used both diagnostically and therapeutically. Attaining a lordotic sitting posture, perhaps even with a lumbar roll3,7 may help many patients to relieve some, or most, of their pain. This simple procedure often helps patients understand the importance of maintaining a lordotic posture as one of the solutions in managing their back pain. To reinforce cause and effect, have the patient return to his/her habitual, slouched posture and continue your history taking until he/she starts to fidget or communicates that the symptoms have come back again. Then, help the patient adopt a lordotic sitting position once more. When the symptoms decrease again, the patient should recognize the cause and effect relationship and through this simple learning experience, the patient will be empowered and educated in regard to the significance of postural behaviour in controlling pain. It is important to ensure that the patient understands how posture affects the symptoms. It is not enough to simply tell the patient to sit up straighter. It must be practiced in order that its significance be internalized.
“Tell me and I’ll forget
Show me and I’ll remember
Involve me and I’ll understand.”
This interactive evaluation of sitting posture becomes a more dynamic, objective assessment of posture and an important learning opportunity for the patient, rather than just a simple observation of whether or not the patient is sitting slouched.
Correct sitting posture has been debated in the past. The Williams protocol advocates a flexed sitting posture and flexion-type exercises. The McKenzie protocol advocates a lordotic sitting posture and either flexion, extension or laterally directed exercises, depending on the symptomatic response of the patient. Trials4,6 comparing the two protocols, found the McKenzie approach to be significantly superior in terms of the length of comfortable sitting time, along with other variables such as pain intensity, post-treatment pain free ROM and SLR. The outcome for comfortable sitting time is speculated to be due, in part, to the difference in philosophies with respect to sitting postures.4,6 Another study7 looked at the effect of either kyphotic or lordotic sitting postures. Results indicated that subjects sitting with a lordotic posture enjoyed a significant reduction in back and leg pain, and that the referred pain shifted back towards the lumbar spine area (centralization). The evidence seems to indicate that, in most cases, a lordotic sitting posture is superior to a kyphotic one.
Once the postural concept has served as a diagnostic tool, the utilization of posture as a therapeutic tool can be explored. This can be achieved during subsequent visits by changing the patient’s awareness of proper posture from an external to an internal control mechanism. Upon observing the patient fidget in his/her current position, help the patient to adopt the correct posture. Encourage the patient to be kinesthetically aware of the position now, compared with the previous uncomfortable position, and the difference in symptoms that are felt. Help the patient to realize how far he/she had to move in order to adopt this modified posture. All of these cues will help the patient begin to internalize awareness of the difference. As time passes, the patient will begin to adopt the correct posture automatically. When the patient self-corrects his/her posture, point it out, and acknowledge the fact that the patient was able to self-correct the posture. Determine what made the patient feel the need to change his/her posture and how the patient knew what new posture to adopt. By reflecting upon these questions, the patient will begin to internalize the awareness and control of posture because the connection will have made between what used to be felt and how the new postural behaviour feels.
When working with chronic pain patients, the subjective and objective clinical presentation may be overwhelming. It is with this patient population that the importance of posture becomes so evident. Instead of getting too complicated with treatment, focusing on postural education and awareness empowers the patient to take responsibility for his/her spinal health and general well being. When patients are able to learn how to sit, stand, walk and perform activities of daily living with less aggravation of the symptoms, they begin to think more positively about their success with treatment. Sometimes the simplest solution is the solution (Occam’s razor).
With all patient populations, clinicians may tend to place too much emphasis on other aspects of treatment and forget the importance of posture. Posture may be addressed early on in treatment and then clinicians ‘move on’. Patients receive so much information and advice in the first visit, that if the clinician does not continue to explain the importance of posture, patients will often forget it. Furthermore, if patients do not make a connection between correct posture and a decrease in symptoms, they will not be intrigued enough to continue exploring postural correction. By continuing to address the significance of posture, patients will integrate it into their habits. Practitioners fail patients when they do not recognize their lack of postural awareness and when postural retraining is not included in the treatment plan. Clinicians need to address this concept on a regular basis to reinforce its importance upon patients and to give them tools to remind them of its importance (i.e. taping them in a lumbar lordosis or in scapular retraction to give them kinesthetic cues that they will feel upon slouching). Giving patients cues on how and when to think about their posture or practice their postural exercises (i.e. every commercial break in their television show, every time their watch beeps on the hour etc.) reinforces the cause and effect relationship between posture and symptoms.
Postural retraining is an important part of most spinal rehabilitation programs. As O’Sullivan et al5 have shown, simply practising erect postures, both sitting and standing, helps to activate the spinal stabilizing muscles, whereas, flexed sitting and passive standing postures can actually have an inhibitory effect on the stabilizing lumbo-pelvic musculature. This could represent further proof that a lordotic sitting posture is superior to a kyphotic one. Interestingly enough, simply practising lordotic (erect) sitting is sufficient to help activate these important stabilizing muscles. The results described by O’Sullivan et al5 suggest that perhaps we do not really need elaborate equipment and exercise programs to help rehabilitate these de-activated muscles, when patients can do it themselves in a more functional way. This method also serves to empower patients and helps to reinforce proper posture at the same time.
In summary, posture should be an integral part of many spinal rehabilitation programs. It can be used diagnostically through educational opportunities in the subjective interview, helping to denote the significance of the cause and effect relationship between proper posture and decreased symptoms. Therapeutically, clinicians can help patients internalize their awareness and control of proper posture by cueing them, both verbally and kinesthetically (i.e. via taping). By consistently referring to proper posture and practising erect sitting and standing, patients will remember and understand the cause and effect relationship and feel empowered about how their posture can affect their symptoms. Furthermore, practising erect postures will help activate important spinal stabilizing muscles in a simple and functional way. It is important to keep this philosophy simple enough that patients understand the significance of this tool as the foundation of their treatment success. As clinicians, we need to remember the magnitude of this important, yet basic tool – POSTURE – and apply it on a regular basis to improve clinical outcomes.
1. Black, K et al (1996) The influence of different sitting positions on cervical and lumbar posture. Spine (21) 65-70.
2. Kisner,C and Colby, LA (1990) Therapeutic Exercise: Foundations and Techniques. Philadelphia: F.A. Davis Company.
3. McKenzie, RA (1981) The Lumbar Spine: Mechanical Diagnosis and Therapy. Wellington: Spinal Publications New Zealand Limited.
4. Nwuga, G and Nwuga, V (1985) Relative therapeutic efficacy of the Williams and McKenzie protocols in back pain management. Physiotherapy Practice (1) 99-105.
5. O’Sullivan, P et al (2002) The effect of different standing and sitting postures on trunk muscle activity in a pain-free population. Spine 27(11) 1238-1244.
6. Ponte, DJ et al (1984) A preliminary report on the use of the McKenzie protocol versus Williams protocol in the treatment of low back pain. Journal of Orthopaedic and Sports Physical Therapy 6(2) 130-139.
7. Williams, M et al (1991) A comparison of the effects of two sitting postures on back and referred pain. Spine 16(10) 1185-1191.