Posture and Pain: Cause and Effect?

In this age of social media and Google, we get a lot of information where some are helpful and some are harmful, and some just plain ridiculous. This is even truer in the area of science, fitness, nutrition and related fields. Search for back pain or neck pain and you will see loads of misinformation regarding “poor” posture and its relation to back and neck pain. And these may all seem and sound legit and right on point since most of this information come from supposed health professionals like doctors, physical therapists, chiropractors, osteopaths, personal trainers and well, so-called wellness gurus. But what does recent studies and more importantly recent research say about this? We who practice a more evidence based protocol to pain science and muskuloskeletal rehabilitation have been spending time debunking this myth and educating the masses. While we see a lot of misinformation citing posture as major cause of not only back and neck pain but also hip and shoulder pains, [and heck, you come with heel pain and they assess your posture]… but there are also a number of articles counteracting these claims based on recent evidences. We just have to know what research say and where to look.

First what is good or proper posture?

My physical therapy textbook in orthopedic assessment describes “ideal” posture if viewed from the side as:

“a straight line [which is the line of gravity] that passes through the earlobe, the bodies of the cervical vertebrae, the tip of the shoulder, midway through the thorax, through the vertebral bodies of the lumbar spine, slightly posterior [behind] the hip joint, slightly anterior [front] to the axis of the knee joint, and slight anterior to the lateral malleolus of the ankle joint.”

So it kind of looks like this…

postural assessment

But is there really such thing as ideal, proper or perfect posture? Aesthetically, yes I may agree so. People wouldn’t want to present themselves with awkward posture. We would want to present ourselves as standing tall, ensuring confidence. But biomechanically, that’s a no. Why?

Perfect posture doesn’t exist… 

Well surprise, surprise – POSTURE like everything else is VARIABLE.

Let’s take a look at this study: Variations during repeated standing phases of asymptomatic subjects and low back pain patients.

This study asked both asymptomatic (353) and LBP patients (83) to repetitively stand 6 times, they found that there was mostly loads of variation between the lumbar curve and position of the sacrum each time they stood.

Study says:

“It can be concluded that standing is highly individual and poorly reproducible. The reproducibility was independent of age, gender, body height and weight. LBP patients and athletes showed a similar variability as the asymptomatic cohort

In the standing position, all investigated cohorts displayed a large inter-subject variability in sacrum orientation (∼40°) and lumbar lordosis (∼53°).

In the asymptomatic cohort (non-athletes), 51% of the subjects showed variations in lumbar lordosis of 10–20% in six repeated standing phases.

29% showed variations of even more than 20%. In the sacrum orientation, 53% of all asymptomatic subjects revealed variations of >20% and 31% of even more than 30%”

This first paragraph alone speaks volumes when it says, ‘An irreproducible standing posture can lead to misinterpretation of radiological measurements, wrong diagnoses and possibly unnecessary treatment.

What does this all mean? 

It means, posture assessments don’t tell much nor do they tell an accurate story about the patient or client.

More evidence indicate that patients with low back pain [or neck pain] and those with no pain have a varied degrees of movement and spinal position in the spine, even when the same subject is evaluated several times.

In other words, if you take one person and do six posture assessments in the same day, you are likely to get six different results. Now multiply that 353 people who are asymptomatic, and 83 people with low back pain, like in this study.

The body is resilient and has many different ways it can adapt. Think dynamic systems theory model. Preaching there is an ideal posture is being dogmatic and quite frankly could create fear of certain movements in certain patients.

We see people with back or neck or shoulder pain with slouched or crooked posture [whatever that means] and we assume right away that it’s the posture causing the aches and pains. But most likely it’s the opposite. The slouching and postural change can be compensatory mechanism for the pain experience.

In short, Correlation does not always imply causation.

 

posture apes

But my neck hurts whenever I am stuck working on my computer or reading a book for a long period of time! Yes that happens to me, and I have a pretty “good” posture when not slouched facing a book or tablet or phone or computer. Well I think we can suggest that certain actions can be associated with pain. We could simply call them aggravating positions or factors. Same maybe true of sitting at a computer but we can’t suggest it’s someone’s posture but the time spent in a certain position. Also it’s probably got to do with not moving rather than the posture being bad. It could be another posture [position] that could cause the same problem if held for a significant length of time. Even staying in an erect, supposedly ideal position held in a certain period of time can cause the muscles to tense up. Ever experienced standing for a long period of time that our legs starts to ache. You aim for a chair or just sit on the floor. It’s what our body is meant to do. Move.

As my Chilean friend, colleague and a Physio professor have said, ” The postural variability, if we can call it, probably allows better and flexible adaptive responses to unexpected demands. And also allows to distribute load on wider surfaces or in different tissues and structures, reducing risks of tissue over demand”

In short, it’s the amount of time spent in a certain position for a prolonged period of time and the lack of movement and posture variability that’s causing muscles to becomes tensed and the nervous system to be sensitized. It’s a bit more complex than that but that’s a good starting point.

What do we do then?

First off, pain is complex and there is no clear cut, one size fits all, strategy to avoid or manage pain. Many factors come into play in the pain experience – biomechanics, psychosocial and the nervous system’s rule, patient’s previous experience of pain, patient’s belief system to name but a few. Even negative information one gets from the internet or from a clinician can reinforce or add up to the pain experience.

In biomechanics, any positive results you might have had changing one’s or your posture can be because of offloading overly stressed tissues that could be causing pain. You’re bent on your computer, your neck or back muscles start to get tensed, you straighten yourself up, and alas, you feel better! So it must be your posture! Not so fast!

That is why I always preach movement! A good physiotherapist educate their patients on the importance of moving often. I prescribe movement. Movement matters because we are movement beings!

Your best posture is your next posture!

So next time someones says they are going to assess your posture you should ask, “which one?”

Hope you learned something interesting and enlightening from this article.

Much of the contents of this blog is from a recent discussion from among my colleagues as the research material cited in this article was posted and shared among us on facebook, especially from my British colleague Ben Cormack who first posted the study on his timeline and attracted some good and interesting comments from our peers [including me].

Ciao.

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Here is an interesting read on one’s experience on being told that her posture is bad and her body broken.. until she knew any better: BS about posture causes pain and suffering.

You can see more articles on topics on pain science, movement and exercises, and a whole lot more on my facebook page: Dynamics Physical Therapy and Performance

For recent research on different topics in physical therapy like effectiveness of certain assessment or treatment, like my page: Evidence Informed Physical Therapy

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Reasons Why Physical Therapy Doesn’t Work Sometimes

We’ve probably heard it said. “Why should I bother going for physical therapy when it doesn’t seem to work?” I had friend whose mother had hip pain. She was about 80 years old but still active and well, except for her recurring hip pain. Her doctor advised her to go for physical therapy but she preferred to use a cane instead. She said it’s just a waste time and money going to PT because it’s not very effective. Indeed there are still many who think that physical therapy is ineffective. And these are not just personal opinions. Some are personal experiences!

So why do some patients have this experience? Why is physical therapy ineffective to some? Or most importantly, when does physical therapy seem ineffective? What makes it inefficient?

Here are a few reason I can think of. These are from me as a practitioner, as well as what patients tell me.

  • Outdated Techniques Including Assessment and Treatment Procedures.

Physical therapy is evolving just like any other branch of medicine. Many traditional treatments have been debunked, thanks to continuing research done to better the profession. Many patients are familiar with physical modalities used in PT clinics like ultrasound, TENS, traction machines, hot and cold packs among others. Many of these machines have now been decalred as outdated, ineffective or simply unnecessary. I do like hot pads for their relaxing effect, and I instruct some of my patients to apply hot pads themselves when they feel sore after doing their home exercises. But in the clinic, unless the muscles are super tensed, I dont use heating pads. There are other hands on techniques that produce better result of relieving muscle spasms; the quicker way. There will be more accomplished in 15-20 minutes with manual and movement therapies than just putting hot pack for the same duration. Just not cost and time efficient!

more to pt than

 

When it comes to assessment, many physical therapists still rely on the old paradigm where postural assessment is standard part of evaluation for various musculosleletal pain. They check for aligment, asymmeties and from there they base their diagnosis and intervention. Postural assessment maybe necessary in some instances but is never enough basis for diagnosing musculoskeletal pains and dysfunctions. A more accurate mode of assessment is movement screens.

[You can read some of the outdated treatments used in physical therapy here!]

  •       More Passive Than Active Treatments. 

Since a more accurate way of assessing musculoskeletal problems are dynamic movements more than the usual static postural assessment and provocative tests, it should follow that treatment should also be dynamic and movement based. Other than the treatments mentioned in the number one reason I gave, there are also newer techniques that physical therapists employ that still fall under passive treatments.

manip

While manual therapy is not really new, its name and use is becoming more and more popular in contemporary practice. So much so that many PTs have made it a panacea in many musculoskeltal and orthopedic problems. These manual therapy techniques can include a variety of techniques ranging from moderately scientific to outright pseudoscientific. In many manual therapy treatments, the patient/client remains a passive recipient of the treatment, whether it’s spinal manipulation, soft tissue works, or joint mobilizations.

This does not mean there is no validity and merit in using passive interventions, but that we need to familiar ourselves with what is effective and promote the patient to move.

In many cases, manual therapy works to decrease muscle tone/spasm, increase joint mobility, and relieve pain. But their effect can be short term if they are not followed by exercises to activate the muscles and restore joint functions.

[You can check some weird manual therapy techniques here!]

  •    Non Compliance with Home Exercise Program

For a successful rehabilitation program, the client or patient must be an active part. That is why a good physical therapist gives the patient home exercises and the patient is expected to do them regularly are prescribed. Equally important is the frequency and duration of the exercises. Just as medications are taken in dosages and frequencies, so are exercises. Some exercises need be done several times a day while some might be done once a day or on alternate days.

Exercises are also progressed while other exercises terminated during the course of rehabilitation. If the same exercises and repetitions are done every session, what is the need for PT? It will be waste of time and resources.

do your exercises

There are some who are pretty compliant but when you ask them to do the exercises again on the next session, you could just shake your head because they got the exercises all wrong… or maybe a little off. That is why I am in the habit of emailing my patients the list of exercises I prescribe them with brief instructions, including repetitions and frequency.

2 weeks

  •     Wrong Exercise Prescription.

Yes, there are physical therapists who prescribe almost the same exercises during the course of rehabilitation. Same exercises for every back pain. Same exercises for every shoulder problem. Same exercises for every knee pain. Sometimes it works. Sometimes it doesn’t. Exercises should be individualized based on assessment and patient’s functionality [Is that even a word”]. And equally important is timing of when to prescribe the exercises. We call it graded movement exposure.

empty can

Another thing that is a bit off with many therapist’s exercise prescription is the intensity. Some therapists are afraid to challenge their patients for fear of aggrevating their problem. So they stick with minimal resistance using the mildest theraband, maybe lightweight dumbbells and ankle weights, and never challenging their patients.

[Some weird and outdated exercises given by some physical therapists here!]

  •     Premature Discharge from Physical Therapy.

finally

This mostly falls on the clients themselves. There are some clients who stop rehab so soon. While I dont believe patients/clients should be kept for a long period of repeated sessions, they should not be discharged so sooner either. Sometimes patients decide to stop having physiotherapy once they feel better and see some improvements. But pain relief is not the only goal for rehabilitation or else we might as well just prescribe analgesics. The most important goal of rehabilitation is return to usual, daily activities without the risk of relapse or re-injury.

And then there are those who give up quickly when they don’t see immediate result. Some patients think that going for physical therapy is like going to a doctor or dentist where certain medication is prescribed, or certain procedure is done and everything goes fine. But rehabilitation of any kind takes time.

i dont always

Patients must remember that at the initial stage of rehabilitation, there will be ups and downs. The patient may feel fine after couple of sessions, depending on the severity of the injury or problem, but then some triggers may cause the symptoms to reappear, even in the absence of real injury or pathology. In some cases, pain may no longer be present but the surrounding tissues [muscles, tendons, ligaments] are still not ready for some specific, complex tasks. That’s the reason why in the later stages of rehabilitation, more challenging movements and exercises are prescribed. And sometimes patients may need to be referred to a strength and conditioning coach or a personal trainer to ensure the patient is ready to return to usual activities.

Get PT 1st.

So these are some of the most common reasons why physical therapy doesn’t seem to work. These are based on clinical experiences as well from experiences of clients themselves. Surely there are cases when other factors are involved and would need additional consult with another professional like a medical doctor [when a damaged tissue need repair] or maybe a psychologist [when experience of pain includes other psychosocial factors]. That’s why it’s always wise to get PT first.

So next time you feel like physical therapy is not working for you or for your significant others, check these reasons first. There are cases when we go see other doctors and dentists for second opinions. It is also wise to go see another physical therapist before you give up.

Wishing you all free, painless, functional movements!

What are other reasons you can add to my list?

Further readings:

Dinosaurs in Physical Therapy- Will a Comet Ever Wipe Them Out?

5 physical therapy treatments you probably don’t need.

Does Therapeutic Ultrasound Work?

Note: Many of the memes used here are from The Awesome Physical Therapist.

 

Education and Exercises – The Cornerstone of Physical Therapy

“If your therapist only does a ‘treatment’ to you and misses out the ‘get it moving/ rehab/ graded recovery / functional recovery process – then its my opinion that your therapist is a complete waste of time”

Louis Gifford
Aches and Pains P.159

In his article Chiropractic and Osteopathy – How do they work?, respected physiotherapist from UK, Adam Meakins wrote:

The lines between physiotherapy, chiropractic and osteopathy have become blurred. As physiotherapists we should be giving only education and exercise-based advice. We believe in self-management, giving patients ownership to get themselves better and not looking for repeat business.

Indeed, the past few years we have seen the crossover of practices among many different rehabilitation specialists. While I don’t have anything against chiropractors or osteopaths, there has got to be distinguishing line somewhere. Good thing, there is… Physical therapists are well known in constantly educating their patients and keeping them actively part in the rehabilitation process instead of just keeping them passive, with the practitioner doing all the work.

Education.

A good physical rehabilitation practitioner must be able to educate their clients/patients properly. Education starts with discussing the underlying condition as accurately as possible. What and where is the problem? Why does the problem exist? Many times patients come to physical therapy to have assurance that there is nothing particularly a major problem with their [insert musculoskeletal problem here]… In the discussion, it is important that the clinician uses non-threatening words to make sure that what we tell our  patients won’t cause a nocebo effect. Nocebo is a detrimental effect on health or symptoms produced by psychological or pyschosomatic factors. In rehabilitation medicine, these factors involve mainly the words that we use when discussing with patients their conditions.

nocebo

“A massive fear inducing nocebo” – Ben Cormack, Physiotherapist

Nocebo effect is particularly common in pain management. Even well trained clinicians use inappropriate words that cause more harm than help to pain patients. Sometimes, these inappropriate words are used intentionally to encourage the patient to to sign up for long term treatments. This happens when the patient is made to believe that some things are wrong with their body and they need a regular or at least a long term, repeated fix. Examples of these are: spinal vertebrae being out of place that need some long term adjustments, some muscular imbalances that need repeated correcting, core muscles being weak causing recurring low back pain… the list could go on! [More about this in future blog, but there already numerous articles regarding these issues].

But what is so threatening with these words? In their article, The Nocebo Effect: How Your Power of Suggestion May Harm Your Clients, Matt Danzinger, a personal trainer and Jonathan Fass, an orthopedic physical therapist wrote:

Words like “fat, scrawny, or weak” are words that harm. Words like “damaged” or “broken,” phrases such as “you’re going to be injured,” or “you don’t move right” can destroy what you are trying to build.

Telling a patient they have degenerating discs, bad posture, displaced sacrum, etc. can be perceived as threat by the brain. And when the brain perceives a threat, real or imagined, pain is produced. Imagine if everyday our patients believe that their posture is bad, they have a bulging disc, their knees are degenerating. How would the brain react to these catastrophic thoughts? We know now that pain and tissue damage are not always correlated. Unfortunately, pathologizing posture and movements is very common and rampant in musculoskeletal medicine resulting in fear-avoidance behavior and catastrophic thinking. I’m not saying that discs or joint degenerations are not real, just not causative factors of many recurring or chronic pain conditions. [Again, this topic needs a totally separate article].

In other words, educating patients regarding their condition is essential part of physical therapy practice. But more important still is to say the right words that are more helpful than harmful.

Exercises.

Prescribing appropriate rehabilitative and therapeutic exercises is one of the most important parts of a real physical therapy program. It is prescribed both in the clinic and as part of patient’s daily home program. Very often, they are prescribed as graded movement exposure wherein the exercises prescribed depend on the patient’s capacity and tolerance at the time of treatment. These exercises are also specific to the patient’s underlying problem – acute injury, non-specific pain, or presence of pathological condition.

While other specialists may administer mainly passive treatment to “fix” the client’s problem/s, physical therapists make use of the therapeutic effects of exercises to relieve pain, increase range of motion, strengthen muscles and improve movement. That’s right, graded movement exposure can actually help relieve pain. So no need to avoid movement altogether. Furthermore, exercises can promote tissue repair after tissue injury, or surgical repair of damaged tissues in the musculoskeletal system through a mechanism termed as mechanotherapy.

I am not in anyway saying that these so called passive treatments like heat, ultrasound, massages, manipulations, joint and soft tissue mobilizations, even kinesio taping have no place in physical therapy. Although evidences of the therapeutic effects of these modalities are weak at best, they can be in some cases they can be helpful. [Ok, so more and more orthopedic physical therapists are discarding their ultrasound machine, and for good reason]. I do spend a great deal of time doing hands-on therapy on my clients or patients prior to giving exercises. They can produce neurophysiological changes in the tissues to make movement drills easier and tolerable. For example, soft tissue work and joint mobilizations can help decrease pain, decrease muscle guarding, and increase range of movements. Exercises are then carried out to help maintain these improvements though activating the nervous system. That is why a good home exercise program, and adherence to these exercises are essential in the over all success of a physical therapy program.

So the next time your physiotherapist gives you only passive treatment without giving you exercises to do in the clinic and to do at home, you are hereby advised that you find another therapist.

gangnam

 

 

References:

A meta-analytic review of the hypoalgesic effects of exercise. Kelly M. Naugle, Roger B. Fillingim and Joseph L. Riley. 2012

Exercise as medicine – evidence for prescribing exercises as therapy in 26 different chronic diseases. B.K. Pedersen and B. Saltin. 2015

Mechanotherapy: how physical therapists’ prescription of exercises promotes tissue healing. K.M. Khan, A. Scott. 2009

Further Readings:

Placebo and nocebo effects in the neurological practice.