For years physiotherapist’s and other allied health professionals including osteopaths and chiropractors have been instructing their patients with low back pain to sit up straight. In previous generations parents commonly told their children to sit up straight, and even resorted to strategies like holding a book balanced on their head to retrain sitting posture.
One of the greatest athletes of our generation, Lebron James, was recently interviewed by TMZ as he got into his Porsche wearing a McKenzie Method lumbar roll to correct his sitting posture.
If it’s important to Lebron James (who basically never misses games due to injury) should it be important to you if you suffer from low back pain?
Over the last few years there has been growing conjecture, even criticism of posture correction and the importance of sitting posture particularly in the last few years from some allied health practitioners. Pain science has become a very popular approach amongst newer clinicians. Many of the pain science advocates (https://www.painscience.com/articles/posture.php) claim there is no such thing as good sitting posture. Even prominent physiotherapist’s such as Peter O’Sullivan claim good sitting posture is a myth created by practitioners that inspires unjustified fear in those with low back pain.
Now I agree with a lot of what Peter O’Sullivan says about back pain, and he makes some great points about the management of back pain (particularly in those with chronic low back pain heavily influenced by yellow flags like fear of movement), but is he correct on the myth of sitting posture?
In stark contrast is the view of another prominent physiotherapist Robin McKenzie, founder of the McKenzie Method (also known as Mechanical Diagnosis and Therapy or MDT). MDT is one of the most heavily researched assessment and classification systems used in musculoskeletal care (May and Aina, 2012).
When interviewed and asked what would benefit the most people who suffer from low back pain Robin McKenzie answered:
“The one thing that would benefit the most people in one hit would be correction of their sitting posture” -Robin McKenzie
So what does the evidence say?
Those that argue against the benefits of sitting posture claim there is no evidence to support it’s importance, and to be fair the evidence is scant. There is little in the way of high quality research to use this as a basis to say posture correction is useful or not. Personally, I find this surprising given the volume of research on low back pain. And this is where those against correction of sitting posture jump in and argue against it.
I am not one of those people!
There are only a few studies available, and problems arise when even trying to agree on terminology and on the definition of what is good posture. Different studies use different methodologies in training sitting posture and standing posture, and not surprisingly arive at various conclusions.
A recent systematic review (Lomas-Vega et al, 2017) looked at 7 trials and their result on postural retraining on low back pain. Their conclusion “reliable evidence that GPR may be an effective method for treating spinal disorders by decreasing pain and improving function”. Even though this systematic review supports improving sitting posture, I do not think it is a great paper. They looked at Global Postural Restraining and defined it as:
“…a method that mainly involves global stretching, breath control, and manual control by the therapist to provide proprioceptive information to the patient”. Huh?? Is this how we look at posture clinically? Certainly not how I practice. I find their explanation of posture retraining baffling.
So, if the evidence does not really give us conclusive information how do we know if posture affects low back pain?
My challenge to those who argue against the importance of posture would be to test it with every patient who has back pain, without bias to prompt the patient.
I am physiotherapist who has predominantly treated low back pain for over 10 years. With the MDT approach the first thing that is done, after taking the patients history, is to correct their sitting posture and determine what effect it has on their pain.
My clinical experience is that in around 70% of patients get immediate relief of their low back pain when the lumbar lordosis is restored (using hands on feedback to find the corrected position). This loss of lordosis is a common flaw in the office worker, and correction is easily maintained with a lumbar roll.
Around 10% say their pain is worse, and they are not the patients’ who I tell to sit up tall and use a lumbar support, in the remaining 20% they will report it has no effect.
So, to be clear, posture and sitting advice is specific to the individual, so to say with a broad stroke it is ineffective is to ignore a potentially significant factor.
Why do so many people get relief of low back pain with simple correction of sitting posture?
These percentages approximate a study done by Hefford (2008), where 70% of low back patients had a direction of movement that made them better (classified as derangement), and of these around 70% responded to extension, which is the direction of restoring the lordosis (curve in your lower back that is formed with posture correction).
If you have low back pain, test this yourself.
One study by Williams et al (1991), found the majority of those who sat with a lumbar lordosis had great reduction in back and leg pain, and back pain reduced and focused into the middle of the back (a change in symptoms called Centralisation which is shown by research to indicate a favourable response and excellent prognosis) in the majority. The study also found a small percentage of the population whose symptoms worsened using a lumbar roll, it logically therefore does not form part of their management strategy.
If your symptoms improve with posture correction, I strongly encourage you to view this next exercise created by Robin McKenzie to learn to maintain good sitting posture for those times you do not have lumbar support (i.e. At a café).
Lebron recognises the importance of posture correction!
So did Robin McKenzie!
So should you!
At very least you should have a therapist that will assesses you to determine if it should be part of your management plan, rather than making assumptions based on a poor collection of research. And if your therapist is not prepared to test to see if it matters to you, a key piece of the puzzle to your pain and discomfort may be missed!
Written by Joel Laing
Physiotherapist at Absolute Health & Performance
Dip MDT (Diploma of Mechanical Diagnosis & Therapy)
Hefford, C. (2008). McKenzie classification of mechanical spinal pain: Profile of syndromes and directions of preference. Manual Therapy, 13(1), pp.75-81.
Lomas-Vega, R., Garrido-Jaut, M., Rus, A. and del-Pino-Casado, R. (2017). Effectiveness of Global Postural Re-education for Treatment of Spinal Disorders. American Journal of Physical Medicine & Rehabilitation, 96(2), pp.124-130.
May, S. and Aina, A. (2012). Centralization and directional preference: A systematic review. Manual Therapy, 17(6), pp.497-506.
WILLIAMS, M., HAWLEY, J., McKENZIE, R. and van WIJMEN, P. (1991). A Comparison of the Effects of Two Sitting Postures on Back and Referred Pain. Spine, 16(10), pp.1185-1191.