Does posture really matter?

A common belief is that spinal pain is caused by sitting, standing, or bending “incorrectly.” Despite the absence of strong evidence to support these common beliefs, a large posture industry has flourished, with many interventions and products claiming to “correct” posture and prevent pain. Unfortunately, many health care professionals still provide advice in line with this non–evidence-based perspective.

Common beliefs about posture don't match up with the evidence we have

Health care professionals and the wider community typically agree that avoiding spinal flexion is the safest way to sit and bend. People are commonly advised to “sit up straight” and to “don’t bend your back to lift”. The assumption is that maintaining these postures might protect spinal structures and prevent back pain. However, these ideas are not based on good evidence. The evidence that we do have is actually quite contrary to these common beliefs - the spine is very robust and resilient, and back pain is multifaceted and cannot be accurately described by something as simple as “bad posture”. 

Protecting the spine is often advocated by the fitness industry. Common advice is that the “core” muscles of the trunk must be consciously activated to maintain a “correct” posture and protect the spine. Once again, this idea is not well supported by research. Read more about the “core” here.

The mainstream media also reinforces the idea that pain can be prevented by avoiding supposedly “incorrect” postures, such as slouching. These fear-inducing messages are oftentimes preying on vulnerable people in pain, in an effort to sell them some gimmicky posture “correction” device, that probably doesn't actually help with pain. 

Despite widespread beliefs about correct posture, there is actually no strong evidence that tells us:

1. avoiding “incorrect” posture prevents back pain
2. any particular posture is more associated with pain than other postures 
3. adopting a “correct” posture prevents/reduces pain and disability

So, based on the highest level of scientific evidence we have, this common picture of different “unhealthy” postures is really just a picture of 5 different healthy and normal postures.

Does this mean that posture doesn't matter at all?

No - there is certainly sometimes value in assessing or changing a posture.

When a clinician (doctor, physiotherapist, occupational therapist etc.) assesses you, there may be aspects of your posture that are relevant. For instance, they may observe overly protective postures, muscle tension, apprehension, vigilance, mood, distress and body language - any of which can provide insight into how you may be dealing with a painful experience. However, it is never as simple as saying - “you have back pain because you are slouching, sit up straighter”. 

It’s also worth mentioning that people come in all different shapes and sizes, with natural variation in things such as spinal curves. It is not at all practical or useful to compare one individual person to some supposed ideal postural norm. 

When it comes to changing a posture, this can sometimes be useful too. You may find that while you are having back pain, certain postures are very provocative. It is reasonable to find strategies to temporarily avoid or diminish the impact of these postures, until symptoms decrease to a manageable level. However, it is very important to state that this does not mean those postures were “bad” or “harmful” or need to be avoided in the future. Just that sometimes temporarily avoiding them can be helpful. On the other hand, for some people, deliberately going into and challenging those painful postures can also be helpful. Pain is complicated, and there is no one size fits all approach. 

7 key messages about posture

To summarise, here are seven key messages about posture. These all come directly from a 2019 review article in the journal of orthopaedic & sports physical therapy by a team of physiotherapists and researchers, who are some of the leading voices in the fields of back pain and spinal health. 

1. There is no single “correct” posture. Despite common posture beliefs, there is no strong evidence that one optimal posture exists or that avoiding “incorrect” postures will prevent back pain.
2. Differences in postures are a fact of life. There are natural variations in spinal curvatures, and there is no single spinal curvature strongly associated with pain.
3. Posture reflects beliefs and mood. Posture can offer insights into a person’s emotions, thoughts, and body image. Some postures are adopted as a protective strategy and may reflect concerns regarding body vulnerability. 
4. It is safe to adopt more comfortable postures. Comfortable postures vary between individuals. Exploring different postures, including those frequently avoided, and changing habitual postures may provide symptom relief.
5. The spine is robust and can be trusted. The spine is a robust, adaptable structure capable of safely moving and loading in a variety of postures. Common warnings to protect the spine are not necessary and can lead to fear.
6. Sitting is not dangerous. Sitting down for more than 30 minutes in one position is not dangerous, nor should it always be avoided. However, moving and changing position can be helpful, and being physically active is important for your health.
7. One size does not fit all. Postural and movement screening does not prevent pain in the workplace. Preferred lifting styles are influenced by the naturally varying spinal curvatures, and advice to adopt a specific posture or to brace the “core'' is not evidence based.

Image credit: Adam Meakins - The Sports Physio @adammeakins 

Acknowledgements and references: 

• Slater, D., Korakakis, V., O'Sullivan, P., Nolan, D., & O'Sullivan, K. (2019). “Sit up straight”: time to Re-evaluate. journal of orthopaedic & sports physical therapy, 49(8), 562-564.
• Kevin Wernli @KWernliPhysio - 7 Surprising Facts About Posture Infographic 
• Adam Meakins - The Sports Physio @adammeakins
• Swain, C. T., Pan, F., Owen, P. J., Schmidt, H., & Belavy, D. L. (2020). No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of biomechanics, 102, 109312.