The Good, the Bad and the Ugly: Spinal Posture

Sarah Mingels

doi:10.37871/jbres1711

ISSN: 2766-2276

General Science . 2023 March 31;4(3):562-566. doi: 10.37871/jbres1711.

Subject area(s)

Musculoskeletal Disorders

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Opinion

The Good, the Bad and the Ugly: Spinal Posture

Sarah Mingels*

Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Leuven University, Leuven, Belgium

*Corresponding author: Sarah Mingels, Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Leuven University, Leuven, Belgium E-mail:

Received: 23 March 2023 | Accepted: 29 March 2023 | Published: 31 March 2023

How to cite this article: Mingels S. The Good, the Bad and the Ugly: Spinal Posture. 2023 Mar 31; 4(3): 562-566. doi: 10.37871/jbres1711, Article ID: jbres1711

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Posture is defined as the position or physical attitude of the body, which serves to maintain stability [1]. ‘Sit Up Straight’, ‘Correct your posture’, and ‘Be aware of bad posture’ are commonly used commands by the general public, teachers and health care providers such as physiotherapists. These short commands reflect some persistent stereotypical beliefs that bad postures relate to spinal pain [2-4]. Terminology such as correct, control, realign, re-educate, and rebalance spinal posture are still popular in health care settings, and focus even more on bad postural behaviour. Although scientific evidence does not support any specific posture causing spinal pain, the general public still holds common beliefs that such pain can be caused by flexed spinal postures [3,5].

Training postural control, i.e. aiming for a posture in which an ideal body mass distribution is achieved, is frequently targeted within the domain of musculoskeletal rehabilitation of spinal pain [6-9]. Unfortunately, improving such postural control can result in overemphasizing training on rather static spinal postures. Such static postures are characterized by small or slow rates of change within a task or given time, meaning they lack variation [10].

Yet, at the same time general consensus exists on the importance of variation in posture, i.e. changes in posture with respect to time, to prevent musculoskeletal (spinal) pain [11-13]. This paradox, postural control versus postural variation training, needs further clinical elaboration. Should patients with spinal pain aim for a neutral posture (i.e. to correct their habitual posture towards a posture in which the cervical spine is lordotic and each intervertebral joint approximately in the middle of its range of motion), or to change their habitual posture more frequently. As an example, results from our recent work revealed a general lower spinal sitting postural variability in people with Cervicogenic Headache (CeH) compared to matched asymptomatic controls (Figure 1) [14].

This new finding could indicate a potential postural contribution to provoke headache [11,14]. We could advise these people with CeH to change their posture more frequently in order to counter the lack in variation. However, such one-size-fits-all approach needs rethinking. First, it cannot be assumed that each patient will benefit from the same intervention [15]. Movement behaviour is an individual trait [14]. Figure 2 visualizes eight individual movement patterns of the lower-cervical spine observed in people with CeH during a 30-minute-laptop-task [14]. Each individual reported headache after the task. Based on these findings it should be reflected if each individual would benefit from identical advice. And although healthcare providers generally still prefer upright sitting postures as optimal, we need to question if it is reasonable, and beneficial to correct flexed habitual sitting postures during functional tasks since both flexed, but also more extended sitting postures were provocative in our sample [16,17]. Maybe it suffices to perform repetitive end-range motions to counteract the negative effects of prolonged habitual flexed or extended sitting postures [18].

Secondly, though it is healthy advice to frequently change the spinal sitting posture, such advice raises other interesting questions. When does a posture change, and how often is such change needed? While several methods have been described in this discussion, a golden standard is missing. Spinal shrinkage [19], postural dynamism or frequency of postural change [20,21], postural behaviour [22], index of variation [23], variance analysis [14], and coefficient of variation [24] are just a few examples used to describe postural change. Others propose categorization in ranges or quintiles to define such changes [20,21,25,26]. Ribeiro DC, et al. [22] defined postural change as exceeding postural thresholds (i.e. lumbo-pelvic forward bending events per minute ≥ 45° flexion) [22]. Niekerk SM, et al. [21] and van Niewkerk SM, et al. [27] defined three categories in high school students to analyse pelvic, thoracic and head postural change 2 to 5°, between 5 and 10° and more than 10° of movement. Movements smaller than 2° were disregarded as system error [21,27]. Brink Y, et al. [25] proposed a classification based on the distribution of the difference for each postural angle (cranio-cervical angle, head, neck, and trunk flexion) measured at two time-points in adolescents. The negative aspect of the distribution of the difference scores indicated movement into extension, whereas the positive aspect of the distribution of the difference scores indicated movement into flexion. The distributions were then divided into quintiles (0-20th, 21-40th, 41-60th, 61-80th, and >80th) [25,26]. Ciccarelli M, et al. [23] used the amplitude probability distribution function. From this, the range between the 10th and 90th percentile was calculated as index of variation. A higher amplitude range indicates larger posture variation [23]. These authors used a second index of variation based on exposure variation analysis [28]. This analysis characterized the duration of uninterrupted periods spend in posture categories [23,28]. In summary, although several attempts have been made to describe postural change, a clear definition of this term (and its frequency), and a transfer to the clinical practice are still missing.

Another point for debate concerns the definition of the ‘optimal spinal sitting posture’ [16,17]. Defining postural change is complicated. Not knowing to which extent a posture needs to change to obtain the optimal posture is a next obstacle. It could even be questioned if such posture actually exists, and if so, if it is relevant within rehabilitation. While debate is still ongoing concerning the optimal (sometimes referred to as neutral) spinal sitting posture, patients, members of the community, and physiotherapists still perceive that this optimal spinal sitting posture is sitting up straight [2,3,16,29]. It is suggested that no single correct posture exists, and that any posture, if only sustained for a period, can cause discomfort and pain [30,31]. Initiatives such as for instance STUFF (Stand Up for Fitness) are developed to disseminate the importance of interrupting prolonged sitting posture [32].

It can be concluded that many gaps need to be filled. Future research should aim to reach consensus on the importance of the individual posture, and its potential contribution to develop discomfort and pain.