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].



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


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.


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.


“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.


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.





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.



Physical Therapy Approach to Pain and Injury Rehabilitation

When I write “Physical therapy approach to pain and injury rehabilitation,” I mean my personal approach in managing various musculoskeletal conditions. And my approach is mostly based on the works of Erson Religioso’s “Ecclectic Approach”, Greg Lehman’s  “Reconciling Biomechanics and Pain Science”, and some of Gray Cook’s “Functional Movement” principles. No, I don’t utilize nor promote Cook’s FMS screens. I only follow how he manages musculoskeletal problems where he starts with mobility and stability and concludes with strengthening. Following all these pattern and principles make it easier for me to treat injuries at a minimum amount of time, and with high success rate. I am not going to talk about specific techniques here but rather the flow of my treatment protocols. Specific techniques will be discussed separately some other time.

So here are the areas I work on when working on patients and clients with pain and/or injuries.

  • Pain Relief

Relief of pain would obviously be the most immediate immediate concern of most clients or patients with musculoskeletal conditions that come for physical therapy. They are in pain and as a result making them less functional and less productive. Treatment to relieve pain will depend on many factors including the stage of the underlying condition [whether acute, sub acute or chronic], the intensity and frequency of pain [constant or intermittent], accompanying symptoms, trigger factors, patient’s general lifestyle among many others. So generally I start my treatment with pain science education. Pain science education is winning half the battle in treating patients with musculoskeletal pain. It helps clients understand how pain works, how the treatments I do can help, and lessen their anxiety and fear avoidance.


Next I do some manual techniques. Touch in itself has calming effects. It can decrease soft tissue tone and relieve spasm. It can stimulate mechanoreceptors in the skin and underlying tissues [nerve, fascia, muscles] that bring about neurophysiological changes in the brain that help desensitize the painful area. [Please note that I did not say release fascia, loosen scars, or break myofascial nodules and any therapist who tells you that has not evolved with the new evidences yet or tricking you with the skills they thought they have].

But pain can be tricky. Much of the pain we experience is an output from the brain and thus there are times the site of pain is not always the site in question. And so adjoining joints and tissues are also checked for any pathology, dysfunction or restrictions. Painful neck, check the shoulders. Painful back, check the thoracic or the hips, painful knee check the hips and ankles… The manual techniques I use depend on the problems I find in the assessments. And they are pretty simple. There are many manual therapy techniques out there that are unnecessary and only help the therapist look cool and seemingly more qualified.

  • Improving Mobility
ankle mobility exercise

Ankle Mobility Exercise

Pain and mobility are usually correlated. In the presence of pain, range of motion is decreased sometimes just owing to the fact that the person in pain will tend to guard the joint, to protect it from triggering more pain, or to avoid causing more harm. When pain is decreased, muscle guarding is decreased and joint range of motion is improved.

But mobility is not just about joint range of motion. In fact in many cases, textbook range of motion in some joints are not necessary for functional activities. The point of mobility drills is not how far you can go but how easily and smoothly you move. Movement patterns and joint proprioception are altered in the presence of pain or injury. Mobility drills have something to do with sending sensory information to the nervous system that can bring about change in movement and perception and improve joint proprioception.

  • Improving Stability

As mobility is improved, stability training comes next. Truth is, stability and movement co-exist in the human body kinetic chain. Mobility and stability are the cornerstone of movement. That is why they come first in many musculoskeletal rehabilitaion. Joint stability refers to the ability of the muscles to maintain or control joint movement or position. It’s training the  muscles and surrounding tissues of the joint to function in coordinated actions under the control of the nervous system. Just like mobility, satbility drills are neurophsyiological. Stability exercises aim to let the nervous system have the musculoskeletal units move in coordinated fashion producing efficient and smooth movements.

core - bird dog

Bird-dog Exercise for Trunk and Lower Back Stability

  • Improving Movement

Efficient movement is constant balance between mobility. After basic mobility and stability training, more dynamic, functional movements are introduced. Speed is increased as needed, and directions are varied. While I introduce mobility and stability initially in single planes, transverse planes and diagonal movement patterns are added.

Walking Lunge with Twist as Movement Retraining

Walking Lunge with Twist as Movement Retraining

Movement retraining follows functional movements, and are modified depending on the person’s daily, recreational and sporting activities. Movement retraining will help break the abnormal movement pattern the injured person has developed as a result of pain, muscle guarding and fear avoidance.

  • Strength and Conditioning

Injury and pain does not only affect mobility, motor control and movement but also strength and endurance and thus affect the body’s overall performance. Resistance exercises with the use of everything from body weight, to resistance bands, to free weights, to compound machines will not only strengthen and recondition the muscles, ligaments, tendons and bones but also help promote further healing.

Yes, we use weights in physical therapy!

Yes, we use weights in physical therapy!

Prof Karim Khan of the British Journal of Medicine explains in an interview podcast that exercise-based rehabilitation relies on the cells of the injured tissue sensing the exercises stimulus, converting the signal to protein synthesis, and repairing tissue. This is why rest doesn’t work.

In the event that my client would need a more vigorous strength, conditioning and functional training, I refer them to a more qualified strength and conditioning professional.

  • Return to Performance
voleyball pt meme

Do the things you love,,, pain free!

The highest goal of any kind of rehabilitation is for the injured person to get back to doing what they love – whether it’s running, or dancing, or sporting activities, or playing with the children. In some cases I go and supervise my clients start their sporting program again. I have had a client who’s been indoor rock climbing for five years. He’s had medial epicondylitis [yes, it’s acute] and pain around muscle guarding. After few sessions with him, I joined him at the indoor rock climbing site as he attempted to start climbing again. I’ve done the same thing with my client who is a professional contemporary dancer.

Don’t let pain and injury stop you… Physical therapy can help in more ways that you realize. A good physical therapist can help you in every step of the way – from your recovery to return to performance.