The following was sent in by Ellen Buckley and is a fantastic rebuttal to yesterday's article entitled "Is Posture Important". I suggest you read yesterday's article first and then come back here to get both sides of the spectrum and come to your own conclusions.

-Jon

I normally find your articles great but I really feel like you've missed the mark here. I think you've misinterpreted a lot of the literature and missed the point of a bunch of other things too. Just putting this out there that I'm a physiotherapist - so while you might think that means I'm biased (and I probably am), I also went to uni for 4 years to be qualified to say what I'm about to say.

I'm going to go point by point through your article which may seem tedious but I think it's important that all of what you said is addressed.

Firstly a massage therapist is not a physical therapist and they shouldn't be doing those kinds of assessments as they're not appropriately trained to. You can't predict who'll have a biceps tear and anyone who thinks they can hasn't studied enough. I personally think leg length discrepancies aren't important and I personally rarely assess them in practice unless there is a good reason to - and minor ones don't make a difference anyway.

I've done a fair bit of training and never come across those postural assessments - I think it's possibly different in Australia than in the US. Anyone who needs a grid to assess someone's posture shouldn't be doing it - if you're trained you can do it just by looking. Maybe trainers should be better trained at assessing posture?

I do agree with what you say in that it's easy to make clients feel disheartened by doing a movement assessment or postural assessment - but that doesn't mean there's a problem with the idea of postural assessment itself, it means there's a problem with how the information is presented to the client. And you can phrase it in a positive way - for example (and this is something like what I say multiple times a day) you have a slightly rounded back, but by doing some exercises and avoiding slouching for long periods, you can improve it.

You're right that there are people with bad posture with no pain, and people with good posture with pain (as there will be exceptions to any rule), but from my clinical experience there is a strong correlation between poor posture and back pain.

Poor sitting posture has been consistently shown to be a strong predictor of low back pain . Moreover when you say that there are studies which have found no correlation - while this is true, more recent studies have found that back pain and posture can be subgrouped, so there is a subgroup who hold themselves actively into extension who have pain, and a subgroup who are in excessive flexion with pain (but if you look at the group as a whole, without subgrouping, it appears like there is no difference to people without pain) .

It is only by being more specific about types of back pain, and subgroups, that you get these differences. Furthermore a correlation has been shown between asymmetric posture and low back pain .

I agree that clients have got to be committed to postural change, and sometimes they won't be, but you can't write off everyone as not being committed to it without trying. One thing that I often do is get a patient out of a bad posture and into better posture, and demonstrate to them that their pain goes away with that. That is a powerful motivator for a lot patients and they get it that it's their posture that's causing (or at least largely contributing to) their pain.

However, you don't have to change everything you do, or be cognizant of your posture all the time to change it. I know this myself as I used to have terrible posture (and a lot more back pain) and while there is an initial period where you have to be reminded, like anything, it gets easier with time - and you definitely don't have to change what you're doing, you just need to change how you use your body when you're doing it.

You mention pelvic tilts - I find that normally they do affect pain and performance, but everyone is different. If you're not sure, why don't you check? If they have an anterior tilt, get them to a neutral tilt and re-assess their movement. Does it make a difference? That gives you an answer as to whether it's important for that client.

Also re: the study you mentioned, any time you look at asymptomatic patients, there is no way to know if they develop low back pain down the track because of their posture. Just because they don't have pain at the time of the study doesn't tell you whether their posture will contribute to their pain down the track.

Onto the upper body - I don't know if you've cherry-picked these studies, but the vast majority of clinical protocols (based on clinical trials) for all shoulder issues recommend postural assessment and treatment of major postural deviations ( is an article for one issue but there are countless others).

Now this isn't to say posture is everything - I think sitting posture is important, and standing posture is less important. I also think that neuromuscular control is more important than standing posture, and that is not something that (as far as I'm aware) personal trainers are qualified to assess/should be assessing (articles have some info on this).

I also think that poor posture and pain is a little like high cholesterol and heart issues (if you ignore all the recent debate around the relevance of cholesterol) - just because you don't have pain yet doesn't mean that you shouldn't do things to address your posture now, before you develop issues.

It's important to understand that a lot of the literature around this is pretty poor quality. Recently the literature on low back pain has focussed more on subgrouping and this where you see more conclusive evidence, but there is still a lot of research that needs to be done.

I think you also need to ask yourself, what is the point of trainers providing these assessments? If there is a thoracic kyphosis, do you know how to reverse it effectively? Are you trained to provide corrective exercises for posture? I've noticed your most recent post on this issue (haven't had a chance to read it yet), and I think the answer is no. I think that it should only go to the extent of - oh hey try and fix this - oh you can't - well either a) get it checked out or b) if it's only minor and not causing you issues don't worry, but let me know if you develop any pain.

I just want to finish with saying I really like most of what your post but I don't think this article should go out without a proper rebuttal. Happy to continue this conversation.

From Jon: Thanks to Ellen for this fantastic rebuttal. My main goal is to start a conversation about these subjects. Nothing that we publish is right or wrong. If we receive high-quality and well thought out arguments we will publish it even if it goes against existing dogma.

If you've looked through the body of research and come to your own conclusion, that's great and I would never tell you to do it any other way. Unfortunately it's more common place for both new and advanced trainers to buy into a system without looking at any quality information to the contrary. Because of that, we publish different opinions.

UPDATE

Lars Avemarie and Jason Silvernail have published a fantastic overview of the literature at http://bloodandiron315.com/2014/02/14/an-in-debth-review-of-the-postural-debate/ and I encourage you to have a read to complete your knowledge of this important subject.

-Jon

About the Author

Ellen is a physiotherapist practicing in Melbourne, Australia. She has works in a private practice and has worked with elite basketball and hockey teams as well as taking Clinical Pilates classes. In her spare time she runs an online lifestyle change business and loves to train herself

References

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