Updated: Nov 22, 2021
We all know what good posture is - upright, erect spine, shoulders down and back, chest forward. And by contrast “bad” posture is hunched back and rounded shoulders, chest caved in.
Rounded posture is blamed for back, neck and shoulder pain. Doctors, manual therapists and the general population all tend to agree that posture influences our pain and health. It just makes sense... or does it?
It turns out that this is just cultural conditioning. There is virtually no good quality scientific evidence to confirm this. But there is a lot of poor quality evidence to support it, which is probably responsible for the widespread misbelief. Many scientific papers say “bad posture is bad” simply because the poor methodology in the experiments leads researchers to confirm this bias). But in fact, more recent high quality research has highlighted the exact opposite - that rounded posture/Upper Crossed Syndrome has little correlation with pain.
UPPER CROSSED SYNDROME
Upper crossed syndrome is a fancy term to describe rounded posture, a theory created by Vladimir Janda in 1987. He suggested that Upper Crossed Syndrome is characterised and caused by tight or shortened chest & posterior neck muscles, while the muscles between the shoulder blades (rhomboids) and across the back (latissumus dorsi and lower trapezius) are weak. This theory has become extremely popular amongst manual therapists as a way of understanding and therefore correcting posture.
WHY IS POSTURE CONSIDERED SO IMPORTANT?
Cultural references condition us to believe what’s “right”. The Hunchback of Notre Dame, Frankenstein’s assistant (and many other “evil assistants”) Dr Evil from [my favourite movie] Austin Powers are just 3. Thus hunched posture has become synonymous with evil and bad. Goodies tend to have “good posture” as standard. Power, grace and elegance are associated with upright posture.
Ballet dancers, soldiers, police officers - they need to look official, authoritative and alert, so standing tall is a necessary part of the job. Donald Trump has famously funny posture. Not sure how relevant it is to this article but I just wanted to mention it because it’s so odd. Could he secretly be a centaur?
In cases of neck, shoulder and back pain, other factors are significantly more to blame than posture. You can read more about that HERE. Despite this, there is still a rather firm misbelief that bad posture leads to bad health such as back pain, joint problems, breathing and digestive issues. These are generally untrue.
Our spines are robust and adaptable and can tolerate a whole variety of positions and movements, depending on our load tolerance and how we use our spine. Any messages to the contrary tend to inspire fear, and fear can be more dangerous than the thing we’re afraid of.
DIFFERENCES IN POSTURE ARE NORMAL and not a sign that something needs to be fixed. There are many natural variations in spine curvature across different cultures and people. One is not better or healthier than another or more potentially problematic than another.
A growing body of good quality evidence is finding that posture does not correlate with pain as much as we once thought. There are people with “bad” posture who have had no pain.
There are also people with severe pain and perfectly “acceptable” posture. Why? Because there is so much more to pain than posture.
So while bad posture is vilified by manual therapists, personal trainers, yoga teachers and the like, it may not be all that bad after all. In my view, we are fixated on posture correction for more because of cultural ideals (appearing confident and strong) than avoiding or relieving physical pain.
Like most manual therapists, I used to believe the old theory of poor posture = problems. I’ve therefore also been guilty of trying to change people’s posture by strengthening the posterior shoulder muscles and stretching the anterior chest muscles (as per Janda’s Upper Crossed Syndrome theory) and was disappointed and dismayed when after the session they reverted back to their normal posture. This is because posture is habitual and very hard to change. Even constant reminders aren’t necessarily helpful because
a) the posture gets “corrected” for a brief moment until either muscles fatigue and people revert back to comfort
b) staying in the same position for a long time tends not to represent realistic situations
c) or they just forget.
What's more important is how we are able to move into and out of different positions.
EXAMPLE: I’ve been working with Gracie for about 6 years. She has fairly poor posture that I, rather arrogantly, felt I could and should change. Six years on and she’s still the same as she was when we first met. But she’s able to perform the posture “correcting” exercises I give her really well and stand beautifully tall and straight when I remind her. When we have discussed this, Gracie realised quite simply that she doesn’t actually want to improve her posture, because she likes it just the way it is.
Another man I have worked with - Steven - constantly complains about his posture, joking that when he catches his reflection in a shop window he wonders who that crooked old man is. He, too, is able to stand straight when directed, but as soon as he starts chatting and gesticulating, he starts hunching again because that's his ingrained, go-to posture.
What does this tell us about posture?...That there’s more to it than just muscle strength and weakness.
Posture is mostly reflexive and habitual, rather than simply a tightness of anterior chest muscles and a weakness of posterior shoulder and back muscles. The muscles have the capacity to hold a person up when required but they get tired, and people forget. Often it’s fatigue that makes us slouch.
POSTURE IS LINKED WITH PERSONALITY
We are not simply (bio)mechanical structures that can be arranged into ideal positions and postures. The biomechanical model completely ignores the fact that we are thinking, feeling, adaptable, often lazy, robust and habitual creatures and that there is so much variation amongst us that there isn’t necessarily a “right” way of anything. (See “IS ALIGNMENT OVERRATED” post for more on this.)
There is a lot of research to suggest that posture is more to do with our personalities than anything else. Here are two crude examples of this:
From day one of osteopathy school we were taught the Standing Examination. This is where you observe your patient standing and look for spinal curvatures, and positioning of heads, shoulders, knees and toes, knees and toes. (And ankles and pelvises, but they weren’t in the song).
There were two people in the class who particularly stood out to me: Andrew and Susan. Andrew was about 5’2” (158cm) and was a typical example of Napoleon syndrome - keen to compensate for his small stature in his behaviour, overbearing personality, and his posture. To make himself appear larger, he stood as tall as he could, pushing his chest forward and lengthening his neck as much as possible. He was desperate to be taken seriously, and in my (somewhat judgemental) opinion, his behaviour in class (shouting out answers, using technical jargon in order to impress) was reflected in his posture and vice versa.
Then there was Susan, a 40 something year old who stood with shoulders elevated, hands clasped in front of her, feet slightly turned in, and a fairly flat spine. She looked like a frightened child. It transpired later that this posture was a result of years of being scolded as a child so standing this way had become ingrained in her. When asked to perform movements that required her to move out of this kind of position, she could, but then went back to standing her way.
Posture can influence our mental state as much as the other way round. You have probably heard of “power poses” such as standing feet wide with hands on hips, or arms in the air. It has been proposed that these postures feed messages into our brain telling us that we are strong and confident, which we then begin to believe.
There have been experiments that found that sitting in a collapsed, helpless position makes it easier for negative thoughts and memories to appear but sitting in an upright position makes it easier to feel empowered.
I’m not sure how much decent evidence there is to truly support this theory, but it's a nice idea and worth a try.
Posture is like body language. So much so that we have common expressions linked with posture such as “stand proud”, “ chin up”, and “get your back up”. Expressions such as these indicate how ingrained into our collective cultural psyche notions of posture are. It’s no wonder then, that we are constantly trying to correct posture.
Posture reflects beliefs and moods, how a person feels about themselves in a particular moment and generally.
Since there is little to no correlation between posture and pain, any “posture correction” comes down to aesthetics. Standing tall and straight says that we are alert and attentive, interested and interesting. And perhaps because we also tend to associate height with strength and power, standing tall has a similar association.
Whatever the reason, often when people try to fix their posture, two problems can arise:
Rigidity - people become so conscious of how they’re standing or sitting that they end up holding the position and lose the ability to move freely around it.
Brevity - Because posture is reflexive and habitual; conscious correction of posture lasts only as long as the person is focusing on it; as soon as they get tired or focused on another task, they revert to their original posture.
Often people who are hyper aware of their posture, such as gym bunnies and ballet dancers, have great posture but ironically become rigid around their upper back and shoulders and often complain of pain there. Could their aches and pains be due to rigidity, rather than their posture, or something else, like simple overuse of certain muscle groups? Hold any position or repeat any action for too long and your muscles can stiffen.
Maybe the problem with bad posture is not so much that it’s bad, but just that people assume it for too long, and that is what causes pain. Likewise “good” posture can also be problematic and painful when held for too long. It can make you stiff and less able to move freely into and around different, erm, postures. As a general rule, if a position causes you a problem (like pain) it’s a sign to change position or move around.
If you really want to correct your posture - first of all be very clear on WHY. Because posture can be linked with mental state, not only physical strengths and weaknesses, it might be useful to tell yourself to stand confidently rather than “correctly”. If you do lack confidence, you might want to try standing how you would stand if you were feeling confident; you could then reprogramme your brain into believing that you are (neuroplasticity).
The take home message is that it’s not black and white, good or bad, right or wrong. It’s highly subjective, activity and mental state dependent and not simply a problem of weak back muscles and tight front muscles. Posture is complex but also not something we necessarily need to worry about, vilify or glorify. So stop stressing about posture, and start moving more and differently.