Wednesday, November 13, 2019

Posture, Pain, and Clinical Reasoning: A Three- Part Series

PART I: Posture, Evidence, and Context

by Josh Lee, DPT, OCS

Image from Canva

Posture has been receiving some dubious spotlight in social media recently, with several new products claiming to help your posture, standing desks, and a myriad of great and not so great posts on how to correct your sitting or work postures (#posture). However, on the other end, there is growing protest from some clinicians to remove posture as an assessment or postural correctives as a treatment. This blogposts series will contain my perspectives on posture and its place in our clinical decision making process.  My intention is to emphasize context in discussions of research and posture.  The goal is not to pit the biopsychosocial (BPS) model against the postural-structural-biomechanical (PSB) model.  T his series is not a research review (although I encourage you all to review the research).  I will not be proclaiming that research is wrong. Instead, I aim to make an argument for clinical reasoning and posture, clinical context, and why I believe clinical assessment of posture is still relevant today.

That being said, I can empathize with the resistance to placing value on posture and alignment as part of the clinical reasoning process for the following potential reasons.
1) Rising evidence of no correlative findings between components of posture and pain may lead folks to feel that we are not staying evidence-based in our assessments/treatments
2) A focus on postures assumedly goes against the pro-patient empowerment approach: “patients are strong and can adapt to anything!” (True, but what if they have run out of adaptations/capacity or what if the tissues are not healthy enough to manage the load? Assess posture to know the lay of the land, then work to gradually load tissues!)
3) There are several mainstream strategies being utilized to “correct posture”. However, without the appropriate clinical reasoning, well-intentioned intervention may feed into kinesiophobic behaviors (examples: “don’t ever slouch in a chair”, “never bend forward”, “Suck in your stomach at all times”)
4) Scapular retracting braces and biofeedback patches attempt to put people in the “optimal position” which usually puts them into a “normalized” anatomical position that may not be optimal for the individual

Here’s why I believe posture to be of value to our assessment/management process.

As Dr. Clare Frank (founder of Movement Links, director of Azusa Pacific Clinical Fellowship of Movement and Performance),  expertly and concisely puts it:

“Posture and pain doesn’t matter… until it does.” 

When a person enters your office with their collective individual life decisions, habits, movement patterns, and adaptations presenting their particular problem, are you prepared to assess the person in their entirety? Are you able to thoroughly listen to their verbal subjective and tie it into your postural observations? Can you then piece together the additional context, evidence, and contributing factors to help structure your physical exam?

As a Movement Links Specialist, using the postural assessments taught in the seminars is integral to structuring the objective exam. The postural assessment is not used for any immediate conclusions, but to utilize the information for context, constantly observing and listening to the person in front of me to gather information on their particular presentation.
I think postural assessments have developed a bad rep over time because of the knowledge gaps around postural clinical patterns and how they provide context and clues to the contributing factors of the individual’s clinical presentation. For example, excessive anterior pelvic tilt, scapular positioning, and other postural “deviations” by themselves are unproblematic and natural adaptations to function…that is, until there is a break in the adaptive capacity somewhere in the movement system and it results in pain. It would only make sense that a lot of the research has been inconclusive regarding any particular relationship between pain and postural deviations. Especially since the human body is fantastic and is capable of adapting to almost anything and deviations have multiple causes as to why they exist with various presentation of pain.

So, when looking at the research and reading that there are no correlative findings of posture and pain, it is tempting to grab onto these results and make a hasty conclusion that there is no need for the postural assessment or to make corrections to posture as such things do not have a relationship to pain anyways. However, this way of thinking can be problematic, because a reliance on approaches based on primarily research conclusions has led to bickering amongst our own rehabilitation family (particularly when there is conflicting evidence) when we should be building each other up. It is problematic when evidence based practice has been skewed to mean “only do things that research has confirmed” vs “integrate research results into practice with clinical reasoning”. In other words, research on alignment and posture should be read with scrutiny and applied with context and clinical reasoning into patient care and not just read at face value. For example, if someone tells me “their increased lordosis is causing their spine to crumble” (real quote from a friend), I can alleviate their fears and contextually provide information from research 15 stating that increased lordosis does not necessarily mean an “issue in the tissue” or pain.

One of the hot debate topics of posture and clinical relevance in particular centers around Dr. Vladimir Janda’s crossed syndromes. For those not familiar, Dr. Janda’s crossed syndromes are systematically organized maps that show predictable patterns of postural inhibition/tightness/shortness in muscles that cross between the posterior and anterior sides of the body with implications on surrounding structures. 1 (If you would like to know more, “The Janda Approach” 1 book is an excellent start) There is both research to support 2-11 and evidence against 12-18  the relationships between components of the lower crossed syndrome and back pain proposed by Janda.  This has led to ongoing debates about the clinical validity of the crossed syndromes for treatment and assessment.
 Lee J, Gerwin R, Reed R, Eberle T, Somarriba G. Chapter 76 Postural Considerations “The Living Engine Light”. In: Donnelly JM, Fernandez-de-las-Penas C, Finnegan M, Freeman J. Myofascial Pain and Dysfunction The Trigger Point Manual. Philadelphia, PA: Wolters Kluwer; 2019

It is of my opinion that Dr. Janda’s observations of muscle imbalances were guidelines for testing and treatment and an organized approach at assessing the status of the central nervous system (Again, “The Janda Approach” 1, great read, 10/10 would recommend). However, the syndromes are commonly generalized and misused as a stretching/strengthening protocol without the foundational understanding of the muscle imbalances, tonic and phasic relationships, and postural synergies (Honestly, this man was considered the “Father of Rehabilitation”, surely one of his namesake concepts was not a simple “what-to-stretch/what-to-strengthen map”). It is similar to how the clinical practice guidelines have become misused as myopic treatment strategies vs their intention as recommendations intended to optimize care with a review of evidence.

So, in practice, it is up to the clinician to utilize the observations and findings from Dr. Janda’s crossed syndromes and their associated deviations and make hypotheses as to how they relate specifically to the individual. By testing the hypotheses and identifying the source and cause of the deviations (i.e. why is the muscle short or inhibited?), there is a systematic unravelling of whether or not these findings are contributing factors to the individual’s clinical presentation, leading to a more effective and specific treatment.

Ergo, I would not give someone a hip flexor stretch simply because I have observed the lower crossed syndrome in an individual or that they have told me they have low back pain and demonstrate an excessive anterior pelvic tilt. Instead, it would make more sense to include certain tests in my exam to discern if it is a contributing factor to their clinical presentation, before making a treatment decision.

The example above illustrates the challenge of being a high quality clinician in today’s healthcare system. It is incredibly difficult to be an up-to-date, caring and passionate, patient prioritizing, evidence-based, and well reasoning clinician under the circumstances that we are in. It doesn’t help that assessing posture with clinical context requires a lot of deliberate practice and reflecting on clinical reasoning, something I still struggle with today. I mean, honestly, it is incredibly difficult enough just to be a normal functioning adult, right? (As I always say, I’m not a morning bird or a night owl, but rather some form of permanently exhausted pigeon. #adultingsucks)
Josh Lee's perspective sometimes in navigating the clinical reasoning process

Not only that, but physical therapists assess and treat one of the most complicated physiologic systems, the movement system. Without the right foundations and clinical reasoning, trying to manage this system can be an absolute nightmare. It is much easier (particularly for new clinicians entering the field) to listen to the experts to tell us what to do, vs thinking for ourselves and being adaptable for each of our patients. Or even to go out and learn new complex systems and concepts without polishing the movement systems foundations in order to use them.

So, I urge all PT’s to do better than normal, go against the path of least resistance, find yourself a mentor who can keep you accountable and away from burn out, and master the foundational movement system basics so you can begin deliberate practice. (#goals)

Now coming to the end of part I, you might be asking at this point (in my head you are at least), “Okay Josh I get it. Evidence and posture requires patient context and clinical reasoning for true application… But you keep talking about ‘clinical reasoning and context’ without saying much about it, so what gives? How does it apply to posture?”

I would love to tell you!  Stay tuned for part II, Posture, Clinical Reasoning, and Chocolate Chip Cookies!

But until then, go forth and move well!

Blogpost by Josh Lee, PT, DPT, OCS

Josh is a physical therapist with Mercer University and Piedmont Hospital in Atlanta, GA. He is a Movement Links Certified Clinician, board certified orthopedic clinical specialist (Mercer University Ortho Residency graduate), current Orthopedic Manual Physical Therapy fellow in training at Mercer University, and primary author of the Postural Considerations chapter in the 3rd edition of the Trigger Point Manual. Josh is an avid  movement system advocate and is passionate about all things human movement related.
1.    Page P, Frank C, Lardner R. Assessment and Treatment of Muscle Imbalance. The Janda Approach. Champaign, IL: Human Kinetics; 2010 (pp. 65, 67, 70, chapter 22).
2.    McGill S, Grenier S, Bluhm M, Preuss R, Brown S, Russell C. Previous history of LBP with work loss is related to lingering deficits in biomechanical, physiological, personal, psychosocial and motor control characteristics. Ergonomics. 2003;46(7):731-746.
3.    Van Dillen LR, Sahrmann SA, Norton BJ, et al. Effect of active limb movements on symptoms in patients with low back pain. J Orthop Sports Phys Ther. 2001;31(8):402-413; discussion 414-408.
4.    Van Dillen LR, Gombatto SP, Collins DR, Engsberg JR, Sahrmann SA. Symmetry of timing of hip and lumbopelvic rotation motion in 2 different subgroups of people with low back pain. Arch Phys Med Rehabil. 2007;88(3):351-360.
5.    Ashmen KJ, Swanik CB, Lephart SM. Strength and flexibility characteristics of athletes with chronic low back pain. J Sport Rehabil. 1996;5(4):275-286.
6.    Mellin G. Correlations of hip mobility with degree of back pain and lumbar spinal mobility in chronic low-back pain patients. Spine (Phila Pa 1976). 1988;13(6):668-670
7.    Ranger TA, Teichtahl AJ, Cicuttini FM, et al. Shorter lumbar paraspinal fascia is associated with high intensity low back pain and disability. Spine (Phila Pa 1976). 2016;41(8):E489-E493.
8.    Malai S, Pichaiyongwongdee S, Sakulsriprasert P. Immediate effect of hold-relax stretching of iliopsoas muscle on transversus abdominis muscle activation in chronic non-specific low back pain with lumbar hyperlordosis. J Med Assoc Thai. 2015;98 suppl 5:S6-S11.
9.    Lee DK, Oh JS. Relationship between hamstring length and gluteus maximus strength with and without normalization. J Phys Ther Sci. 2018;30(1):116-118.
10. Arab AM, Nourbakhsh MR, Mohammadifar A. The relationship between hamstring length and gluteal muscle strength in individuals with sacroiliac joint dysfunction. J Man Manip Ther. 2011;19(1):5-10.
11. Heino JG, Godges JJ, Carter CL. Relationship between hip extension range of motion and postural alignment. J Orthop Sports Phys Ther. 1990;12(6):243-247.
12. Walker ML, Rothstein JM, Finucane SD, Lamb RL. Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance. Phys Ther. 1987;67(4):512-516.
13. Laird RA, Kent P, Keating JL. How consistent are lordosis, range of movement and lumbo-pelvic rhythm in people with and without back pain? BMC Musculoskelet Disord. 2016;17(1):403.
14. Laird RA, Gilbert J, Kent P, Keating JL. Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014;15:229.
15. Nourbakhsh MR, Arab AM. Relationship between mechanical factors and incidence of low back pain. J Orthop Sports Phys Ther. 2002;32(9):447-460.
16. Dieck GS 1985. An epidemiologic study of the relationship between postural asymmetry in the teen years and subsequent back and neck pain. Spine, 10(10):872–877.
17. Papaioannou T, Stokes I, Kenwright J 1982. Scoliosis associated with limb-length inequality. J Bone Joint Surg Am, 64(1):59–62.
18.  Poussa MS 2005. Anthropometric measurements and growth as predictors of low-back pain: a cohort study of children followed up from the age of 11 to 22 years. Eur Spine J, 14(6):595–598.

1 comment: