Posture: slouch more, worry less

Every day we are bombarded from all directions with messages about posture. You constantly hear to avoid slouching and instead sit or stand up straight. These messages frame slouching as being harmful and often claim that it causes pain. Furthermore, some people will even go as far as taking x rays of your spine and analyzing the curves. They will claim that your normal spinal curvature is causing you pain and that they can fix it!

For this article I will be discussing the evidence around posture and that it is ok to slouch. So please, get comfortable and sit or stand however you would like while reading this article.

Bending your back isn't bad

Let’s start off with the low back and work our way up. Most of the messages for sitting up straight talk about preventing low back pain; however, no high quality evidence has established any association with sitting posture and development of low back pain.^1-3 Now, when we look at people who are already experiencing pain, they tend to actually have higher levels of trunk muscle activation (abs and low back muscles) and less movement through their back.¹ This decreased movement may be to avoid positions that provoke the pain. One important point is that just because a position is painful, it doesn’t mean that it caused the pain, but it may be beneficial to TEMPORARILY decrease the amount of time spent in that position, then slowly reintroduce that movement as you improve.¹ This was demonstrated in a study where they had individuals sit on a backless stool for 2 hours and watch a DVD (this is a pretty brutal experience if you ask me). They found that those who currently had back pain benefitted from avoiding end range flexion.⁴ To clarify, some flexion (AKA bending) was still demonstrated, but they only avoided going to the extreme.

To make sense of the information, bending at the back isn’t bad and won’t cause low back pain. The advice to sit up straight in order to avoid back pain is just straight up wrong and not based on evidence. It could potentially be an aggravating position if you already have pain, just how any other position could be aggravating, but it could also be relieving. So the best posture is one that is less aggravating, whatever it may be.

Relax your shoulders and slouch

Moving onto your thoracic spine/mid and upper back. Again, we do not see an association between posture and pain here,⁵ score 2-0 for sitting and standing however you want. One thing that was found with this area, was the potential for sitting in an end-range slouched posture to have small decreases on how high up you can raise your arms (flexion and abduction), and a small increase on how much you can turn your arm in (internal rotation).⁵ A couple things here: 1. A little bit of range of motion doesn’t matter much and won’t significantly impact your life in any way and 2. The posture was held during these tests, so this decrease in range of motion is gone as soon as you move out of the big slouch. So all in all the findings on range of motion are pretty useless and don’t make any significant impact, since they only relate to that one posture, and ignore the dynamic nature of human movement.

But what about forward head posture!?

Finally we have the neck! One thing that has been made up is the infamous text neck. When looking directly at ‘text neck’ and phone use, yet again we find no association between the use of a phone and neck pain; and going even further, there is no association between how many hours you spend on a phone, or how far forward your head is flexed when you are using the phone, and neck pain!^6,7 This isn’t all that new since people have been looking down at books, newspapers, etc. with the same neck posture that people do with phones now for a very long time… Sometimes a little bit of critical thinking can go a long way.

Ok, if we take phones out of the equation and only look at neck posture, do we see any association there? Again, it is shown that forward head posture with slouching does not predict or cause neck pain.^8-10 In fact, sitting with a slouched posture was demonstrated to possibly be protective against neck pain over 5 years⁹ so go ahead and slouch!

X ray pseudoscience

Finally, the terrible and non-evidence based practice of assessing your spinal curvature and then trying to change it is not backed by the evidence, since altered curves don’t offer any predictive or diagnostic significance.¹⁰ When looking at the MASSIVE range of angles that are normal for your neck, we see that it can be from almost 0 to just over 35 degrees in pain free individuals, when talking about lordosis.¹¹ That range is only there because those were the lowest and highest numbers in the studies, therefore curves lower and higher than that may also be normal and not cause pain. If you step into an office and they x ray your spine and tell you they need to fix your curves, do yourself a favour and run far, far away.

No posture is a bad posture

To tie everything together, it really doesn’t matter how you sit or stand, and your posture does not increase your chances of developing pain. The old, non-evidence based notion that you have to sit or stand up straight is a little weird and militant to me, instead we should probably just sit and stand in whatever posture we find comfortable. If sitting slouched is comfortable for you, great. If sitting straight is comfortable for you, also great.

As always, go out there and move!

References

1. Slater D, Korakakis V, O'Sullivan P, Nolan D, O'Sullivan K. "Sit Up Straight": Time to Re-evaluate. J Orthop Sports Phys Ther. 2019 Aug;49(8):562-564. doi: 10.2519/jospt.2019.0610. PMID: 31366294.
2. Swain CTV, Pan F, Owen PJ, Schmidt H, Belavy DL. No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. J Biomech. 2020 Mar 26;102:109312. doi: 10.1016/j.jbiomech.2019.08.006. Epub 2019 Aug 13. PMID: 31451200.
3. Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. 2011 Apr;15(2):131-8. doi: 10.1016/j.jbmt.2011.01.011. PMID: 21419349.
4. Laird RA, Kent P, Keating JL. Modifying patterns of movement in people with low back pain -does it help? A systematic review. BMC Musculoskelet Disord. 2012 Sep 7;13:169. doi: 10.1186/1471-2474-13-169. PMID: 22958597; PMCID: PMC3466154.
5. Barrett E, O'Keeffe M, O'Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016 Dec;26:38-46. doi: 10.1016/j.math.2016.07.008. Epub 2016 Jul 21. PMID: 27475532.
6. Correia IMT, Ferreira AS, Fernandez J, Reis FJJ, Nogueira LAC, Meziat-Filho N. Association Between Text Neck and Neck Pain in Adults. Spine (Phila Pa 1976). 2021 May 1;46(9):571-578. doi: 10.1097/BRS.0000000000003854. PMID: 33290371.
7. Bertozzi L, Negrini S, Agosto D, Costi S, Guccione AA, Lucarelli P, Villafañe JH, Pillastrini P. Posture and time spent using a smartphone are not correlated with neck pain and disability in young adults: A cross-sectional study. J Bodyw Mov Ther. 2021 Apr;26:220-226. doi: 10.1016/j.jbmt.2020.09.006. Epub 2020 Sep 28. PMID: 33992248.
8. Richards KV, Beales DJ, Smith AJ, O'Sullivan PB, Straker LM. Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents. Phys Ther. 2016 Oct;96(10):1576-1587. doi: 10.2522/ptj.20150660. Epub 2016 May 12. PMID: 27174256.
9. Richards KV, Beales DJ, Smith AL, O'Sullivan PB, Straker LM. Is Neck Posture Subgroup in Late Adolescence a Risk Factor for Persistent Neck Pain in Young Adults? A Prospective Study. Phys Ther. 2021 Mar 3;101(3):pzab007. doi: 10.1093/ptj/pzab007. PMID: 33444448.
10. Grob D, Frauenfelder H, Mannion AF. The association between cervical spine curvature and neck pain. Eur Spine J. 2007 May;16(5):669-78. doi: 10.1007/s00586-006-0254-1. Epub 2006 Nov 18. PMID: 17115202; PMCID: PMC2213543.
11. Guo GM, Li J, Diao QX, Zhu TH, Song ZX, Guo YY, Gao YZ. Cervical lordosis in asymptomatic individuals: a meta-analysis. J Orthop Surg Res. 2018 Jun 15;13(1):147. doi: 10.1186/s13018-018-0854-6. PMID: 29907118; PMCID: PMC6003173.