Posture

I'm torn on postural assessment, as will be evident to anyone who manages to wade through the following mess of vague opinions and anecdotal ramblings. I’ve learned it in different forms from at least seven different teachers that I can think of off the top of my head, from tuina and sports medicine acupuncture to trigger point work and different manual assessment/treatment systems taught by massage therapists, PTs, osteopaths and chiropractors. And I have talked a lot with people who learn other systems like PRI.

In general, I’ve seen too many patients with pretty good posture with all of the symptoms that we normally associate with postural imbalances, and too many people with horrendous postural distortions who are symptom-free. I’ve also seen too many experienced therapists of all stripes look at the same patient, at the same time, and disagree on simple, easily quantifiable measurements, like which shoulder or iliac crest is higher, let alone more subtle things. As I’ve gotten more experienced over the years and trust my assessment skills more and more, I actually trust my ability to accurately assess posture and correlate it to the patient’s symptoms much less now than I used to.

Plus, the research around postural distortions seems to point to them being very poorly correlated with symptoms, especially for things like back pain. So, for instance, I’ve almost completely stopped worrying about anterior pelvic tilt, except in extreme cases. I put much more emphasis on muscle testing, ROM, movement assessment and palpation for things like trigger points to figure out what to work on. I use special tests as well, but I rely on them much less than I do for the more basic assessments.

On the other hand, postural assessment is a great way to develop rapport with patients. But this can be a double-edged sword - they really love it when we pay attention to it, because everyone knows they have poor posture, and they also love having all of the ideas they have about how uniquely unbalanced and horrible their posture is confirmed by a medical authority figure. Their posture also easily becomes a scapegoat in their mind for their problems, and it is very easy to reinforce that idea.

I find it also helpful in the same way taking the pulse is helpful – it is a formal way, at the beginning of the assessment, to focus my attention on the patient in the particular way I need to for that kind of work. It’s almost like an attentional warm-up for the rest of the physical assessment.

On the psychoemotional side of things, posture is one of the major ways we signal to other people where we feel we are in the social hierarchy. We don’t like talking about things like status and dominance and submission in the US, but that is basically the information that posture broadcasts. “Healthy” posture and movement – upright, open chest, taking up space, moving slowly and relaxed – is what socially dominant primates do. The major signs that we associate with poor posture – forward head posture, collapsed chest, taking up less space – are ways of signaling to others that you are not a threat, so please leave you alone. It’s amazing how consistently patients tell me how weird it feels when I teach them to sit on a chair with good, upright posture. They all feel very vulnerable at first, like they don’t want to attract other people’s attention or seem too confident or capable or enthusiastic. Those are all things that are not cool.

What does seem to make a big difference, much more than static posture, is movement assessment. Someone can have really weird, altered scapula positioning when they are standing still, but you have them move through flexion and abduction and it moves exactly as it should, where someone else with perfectly normal scapular positioning at rest might have a really disrupted scapulohumeral rhythm or tons of winging as soon as they start to raise their arm. And it’s the movement aspect that seems much more important clinically. That’s something I learned from Mike Reinold’s work.

The same seems to be true for lumbar motion and back pain. In the patients I’ve seen, the resting position of the pelvis often has very little to do with symptoms, whereas the ability of the patient to actually anteriorly and posteriorly tilt the pelvis, coordinating the flexion and extension of the lumbar spine and hip joints, is much more significant.

So my basic approach has become more like – look at posture, but don’t worry about it unless it’s glaringly, unambiguously distorted. But when you look at movement, have an ideal in your head for what it should look like and ask yourself “could that be better in any way?” and be really strict. That’s the approach they teach in the SFMA, and I’ve found it to be far more useful in clinic than being strict about posture.

Having said all of that, I do teach basic posture exercises to almost every patient, but not to try to change their posture, necessarily. It’s more to make sure that they have the motor control and muscular endurance in the important stabilizing muscles of the neck and trunk. As long as they have that, their symptoms seem to get better even when their posture doesn’t visually change much. And they start to feel more aware and grounded in their environment as well.