Too Uptight about Sitting Upright

My husband's posture while studying

When I was a physiotherapist, posture was one of the most common topics of conversation with my patients. People would say, “if I didn’t have such bad posture, I wouldn’t have back pain” and, “my neck would feel a lot better if I didn’t slouch all the time.”

In this post, I’m going to set the record straight about commonly held beliefs about posture, and offer a potentially better way to think about it.

Posture Myths

It seems like the association between posture and pain has been around forever. The thinking was this - if you have bad posture, you’re more likely to get pain or make your existing pain worse. Simple, right?

But, this thinking breaks down in a few of ways:

1.  What is bad posture?

Posture is the way we hold ourselves in standing or sitting. That’s it; it’s not inherently good or bad.

When you think about good posture, it’s usually upright with the head aligned with the shoulders. “Bad posture” looks like the opposite, with the head forward and the back rounded.

But let’s clarify something: just because you don’t like the way someone holds themselves in space doesn’t mean it’s bad. As a society, we seem to associate slouching with laziness, and standing tall with discipline. This is a moral judgement, not a scientific fact.

If I see a patient for muscle or joint pain, of course I look at their posture. However, in the past 10 years, I haven't once told someone they have bad posture. I say that we're all built differently, and then I assess whether their posture is contributing to their pain.

Which brings me to my next point...

2. Does posture actually contribute to pain?

If you Google “bad posture,” you’ll find a million ways that bad posture can harm your health. Did you know that bad posture can cause headaches, disc herniations, and incontinence?

Reference please!

What you won’t find in your Google search is sufficient (or any) evidence to back up these claims, even on reputable sites. And if you do, please post the reference in the comments, because I’m tired of searching for one.

Part of this might be the fact that research in this area is limited. Not to be too cynical, but there’s not a ton of money to be made from telling people their posture is fine as is.

Another reason we're lacking research might be that the belief that a slouched posture is the root of all evil is so ubiquitous that people don’t feel they need to back up their claims.

Either way, here’s the evidence I found:

• A head-forward posture didn’t contribute to shoulder pain as per this systematic review

• There was no association with work-related posture and low back pain in this recent cross-sectional study

• There was no statistically significant association between forward head posture and neck pain in this systematic review and meta-analysis (the authors’ conclusions in the abstract aren’t supported by the results – a good reminder to read the whole paper, rather than take the authors’ conclusions at face value.)

• In this randomized controlled trial, there was no significant difference in the incidence of musculoskeletal pain between computer-users who received posture intervention those who didn’t

This list isn’t robust, because the literature isn’t robust. Studies on posture and pain vary widely in their definitions of what bad posture is, how it’s measured, and the study's outcomes. Despite my deep dive into the research, at best I can say that the evidence is mixed.

3. Posture is very challenging to change

Ok, let’s say compelling research comes out that shows that a certain type of posture causes pain. The next piece of the puzzle is to look at how to actually change posture.

Have you ever told yourself you were going to start sitting upright from now on? How long did it last? I’ve tried, and without intense intervention, my posture goes back to normal in approximately 30 seconds.

Researchers have studied Kinesio taping, corrective exercises, occupation-specific equipment changes, wearable sensors,  smartphone apps, and different combinations of these interventions to see their effects on posture and/or pain.

Let me sum up the results: there’s a lot of work that goes into minimal effect.

As anyone who works in healthcare knows, behaviour change is HARD. If I’m working with a patient who has musculoskeletal pain, I’m going to go for the low-hanging fruit. With spinal pain, this includes reassurance and advice to stay active, the two mainstays of treatment.

Overall, there are many ways that I can help people with pain. Unless their posture is significantly contributing to their pain (more on that later), I'm not going to put all my focus on changing someone's posture for very little effect.

How to Address Posture

As healthcare providers, we always ask, “what makes your pain worse?”  In the absence of clear evidence about posture and pain, I take the following approach:

If my patient says their neck pain is the worst after sitting at a computer for 4 hours, I’d suggest they take a break from sitting every hour, or put a roll behind their low back every so often (like a rolled up towel).

Likewise, if my patient says their low back pain is much worse after an hour of standing, I'd suggest they sit every 30 minutes or take a stretching break. They could even try standing with one foot on a stool.

In both scenarios, I advise how changing up posture might help. Patients can pick what might work for them, try it, and gauge its success.

Next, I reinforce that the best thing you can do for pain is stay active in your day-to-day life. I reassure my patients that pain doesn’t mean harm (after I’ve ruled out red flags), and that they can choose to sit or stand in a way that feels comfortable for them.

If someone doesn’t have pain and asks me if they should fix their posture, I tell them I don't recommend it, but that they can choose to change it if they want. I go into my spiel about how we're all built differently, how people who slouch might never end up with pain, and how people with very upright posture can have tremendous pain.

I then say that there are plenty of healthy habits that have been shown to help reduce pain and improve wellbeing. I'd highly recommend they put their time and effort into some of these high-value behaviour changes.

If you want to change your posture to feel better, go for it! There’s nothing wrong with trying something out to have less pain. However, there's harm in shaming patients about their natural posture and recommending all sorts of intense interventions that have minimal/no benefit.

Please let me know your thoughts!

Stay well friends,

Dr. Kuhnow

This post is meant for educational purposes only, and doesn’t replace advice from your qualified healthcare professional.