Health-conscious people are haunted by the idea that they “should” correct their posture, and many fight a chronic, uncertain, and tedious battle against self-imposed or careless crookedness, primarily as self-defense against common problems like neck pain, headaches, and especially low back pain. But is it a wild goose chase? Can any aches and pains be traced to “poor posture” in the first place? Even if they can, is it actually possible to improve posture? The characteristic ways that we sit and stand and walk are among the strongest of all habits, with deep roots in personality — and so changing your posture may be just as difficult as quitting smoking or potato chips. It had better be worth the effort!
After working as a massage therapist for many years, I became confident that poor posture is a “real” thing1 — a genuine source of partially preventable physical stress and therefore a factor in chronic pain, mostly later in life. But it’s not a straightforward business, this posture stuff! There aren’t many “easy wins” for people here. And there’s plenty of potential to waste time and money — or even get hurt.2 Delving deeper into the topic as a journalist, studying the scientific literature and learning more from countless readers and experts, I have developed many reasonable doubts about posture’s importance. In particular, I believe that many health professionals pathologize posture, exaggerating its importance to justify costly therapy — all with good intentions, of course.
This doorstopper of an article thoroughly explores strategies for postural improvement that may be helpful, but I also explain why the idea of “poor posture” is mostly much ado about nothing — a problem in theory, but a minor one in practice. If your main issue is unexplained or stubborn aches and pains, there are probably better ways to spend your time than reading this, such as getting a nice massage, or being more physically active … which trumps almost all considerations of posture! How’s that for a tempting introduction? Er, read on?
TABLE OF CONTENTS
- 1 Introduction
- 1.1 What is posture?
- 1.2 What poor posture is not: Upper-Crossed Syndrome (and its ilk)
- 1.3 What is “poor” posture?
- 1.4 Does posture matter?
- 1.5 What are the (physical) risks of poor posture? Part 1
- 1.6 Postural stress versus poor posture
- 1.7 What are the (physical) risks of poor posture? Part 2
- 1.8 Vulnerability versus “the posture did it”
- 1.9 What are the (physical) risks of poor posture? Part 3: Arthritis
- •1.10 What are the (emotional) risks of poor posture?
- 1.11 Is the goal of good posture to “stand up straight”? To be “aligned”?
- 1.12 What is good posture?
- 1.13 Can you change posture?
- 1.14 Should you try to change your posture?
- 2 How do you improve posture?
- 2.1 Improving posture by force of will
- 2.2 Address major systemic barriers to success
- 2.3 Visualize, dramatize, and role-play
- 2.4 Trigger self-awareness with reminders
- 2.5 Practice makes perfect: spend deliberate time in a different posture
- 2.6 Use props and tools
- 2.7 Improving posture by taping
- 2.8 Aversion therapy: make the “wrong” things less appealing
- 2.9 Stretching to improve posture
- 2.10 Improve posture with general activity
- 2.11 Add some instability to your life! Improve posture by challenging it
- 2.12 Ergonomics: the art of eliminating postural stresses
- 2.13 Case study of a bad example
- 2.14 Conclusions
- 3 Appendices
- 3.1 Resisting postural assessment, or how I made a newbie massage therapist cry once
- 3.2 What’s new in this article?
- 3.3 Further Reading
- 3.4 Notes
Posture is not a position, but a dynamic pattern of reflexes, habits, and adaptive responses to anything that resists you being more or less upright and functional, such as:
- Gravity, of course!
- Awkward working conditions, which may be unavoidable (nurses must lift patients!), or self-inflicted and correctable (lousy ergonomics).
- Abnormal anatomy.
- Athletic challenges.
If you start to tip over, or lose the stability you need for a task, postural reflexes kick in and engage muscles to pull you into a more or less upright and/or functional position again. The biological systems and tricks that keep us upright are neat — and surprisingly poorly understood.3
Posture is the embodiment of your comfort zone. At worst, it can be like a cage.
Posture is also more than the sum of those parts, more than “just” a collection of righting and stabilizing reflexes — it is the way you live, the shape of your flexible “container,” the physical manifestation of your comfort zone. We habitually hold ourselves and move in ways that serve social and emotional needs, or avoid clashing with them: posture can be submissive or dominant, happy or sad, brave or fearful, apathetic or uptight. The challenges and rewards of trying to change posture are not just musculoskeletal, and it can be a personally profound process. Patterns and behaviours that lead to trouble are usually strong.4 This article does not get too “deep” and mostly sticks to the musculoskeletal issues, but the potential profundity of posture deserves a nod.
The best-known example of a common type of poor posture is undoubtedly “Upper-Crossed Syndrome” (UCS). It sounds impressively technical. Named by a Czech doctor and researcher, Vladimir Janda, it is the apex of clinical storytelling about posture in therapy culture, and the prototypical “muscle imbalance” theory. No idea about bad posture has ever been both this popular and “advanced.”
What is it? Just head and shoulders forward, mostly, with several complicated assumptions about its causes and consequences. In UCS, your muscles are like dysfunctional ship’s rigging: some are weak and loose (inhibited), while others are too strong and tight (facilitated). Viewed from the side, you can draw diagonal lines between these groups that cross. (There’s a Lower-Crossed Syndrome as well, but it’s much less famous.)
Dr. Janda was a pioneer. He did good work with the information he had at the time. But he was probably mostly wrong about UCS.5 The rest of the article substantiates this.
Muscle imbalance theories have not done well over the last couple decades. Jason Silvernail, Doctor of Physical Therapy, comments: “There is almost no data to support these ideas and to my knowledge there never has been.” Research has relentlessly shown that professionals have trouble agreeing on exactly what’s wrong, and the “tightness” of muscles doesn’t seem to have much to do with their strength, or with pain, or really anything that anyone can actually work with. If certain muscles were actually weak in everyone exhibiting a certain posture, and those people tended to have certain problems, then it would make sense to try to strengthen those muscles specifically. But they aren’t, and they don’t, so it doesn’t. Treating people as if they have UCS — with targeted stretching, strengthening, and massage, say — doesn’t work any better than generally getting more exercise.
Nor is any of this surprising given where the science has gone. In general, it has become clear that the “behaviour” and condition of individual muscles is mostly trivial compared to the potent role of the central nervous system as the dictator of almost everything about both function and sensation. In short, it’s not “muscle imbalance” that makes people slump and hurt — it’s a brain thing, and UCS is an effect instead of a cause … or just a fantasy. In fact there probably is no UCS pattern at all — no “cross” of weak/tight muscles. There is just a common posture, plus the panoply of human aches and pains that come and go like aurora borealis (most of which still cannot be specifically explained and probably never will be).
Ultimately, UCS is just a good story Dr. Janda told in the absence of good data. It was a nice idea at the time, but it has become quite obsolete. So why is this vision of poor posture still so popular? Jason Silvernail again:
It’s accessible to a wide variety of ‘practitioners’. Since it involves muscular assessment, everyone from physicians to personal trainers to physical therapists, chiropractors, athletic trainers, massage therapists and strength coaches could use this approach with their patients or clients. Both clinicians (physicians, physical therapists, chiropractors, athletic trainers) and fitness and service professionals (personal trainers, strength coaches, massage therapists). Those with rigorous academic education at doctoral or postgraduate level (physicians, physical therapists), those with college education (athletic trainers, strength coaches, some trainers) and those with trade school or certification training (personal trainers, massage therapists). Huge numbers of different people in different fields could use this. A marketing dream. It provides a simple solution to a complex problem that leverages deeply embedded cultural ideas that are far more powerful than scientific data.
That’s why these crossed syndrome type things make no sense whatsoever but are not going away any time soon. People will be talking about this brilliant insight for another 50-odd years. I wonder if Janda would [facepalm] if he heard how people were unable to move beyond this idea, and had more fidelity to this particular product/idea than to the process he advocated.
This is what skeptics mean when they say that there is no such thing as bad posture — and I completely agree with the spirit of that position. But there is also more to “poor posture” than UCS. Or perhaps I should say there’s less to it …
My definition of poor posture is simple: any habitual, self-imposed positioning that causes physical stress, especially coping poorly with postural challenges. A postural challenge is anything that makes it harder to maintain a comfortable posture, such as “work.” A major source of postural challenges in all our lives is awkward tool use, also known as crappy ergonomics.
Sitting for hours with your knees tucked sharply under your chair is a classic example of a poor posture. No one has to sit like that! But it is a hazard to kneecaps6 — a completely avoidable hazard, which most people fail to avoid because they just don’t know how knees work.
If anyone ever tells you there’s no such thing as poor posture — a popular skeptical perspective — that example is a fine rebuttal, and there are certainly others.7 How much poor posture actually matters is a separate question, but for sure there is such a thing.
What about postural laziness? This is specifically what most people visualize when they think of poor posture, thanks to the Puritans:8 slouching, basically. The avoidance of postural challenges leads over time to poor postural fitness. If you avoid postural challenges enough, eventually you’ll have trouble coping with them when you have to … and so we’re back to the first definition.
Comic by MimiAndEunice.com, which is a lovely place.
Other than just letting themselves go to pot, why would anyone respond in an ineffective way to life’s postural challenges? Weakness, mood, pain, hang-ups, fatigue, fear, stress, and more!
You’re really off the poor posture hook if your response to a postural challenge just can’t be helped.9 For instance, an old man may walk stooped over because he has spinal stenosis and it really hurts to stand up straight. That’s not “poor posture.” All that stooping is certainly tiresome, but it’s the lesser of two evils, and it’s the same postural compromise that everyone with painful stenosis chooses. But for a young man, presumably without stenotic back pain, the same posture would be an unnecessary stress—and certainly “poor” and worth fixing, if possible.
Of course, for the most part young men do not stoop like old men …
Daniel watched Isaac gain a couple of inches in height as he remembered the erect posture that Puritans used to set a better example.
~ a fictionalized Isaac Newton and his Cambridge roommate, Daniel, in Quicksilver, by Neal Stephenson
It turns out that people naturally avoid the most ineffective responses to most significant postural challenges, because homo sapiens is naturally allergic to physical stress. And although postural laziness might seem obviously evil,10 people also naturally tend to keep up their postural fitness for the things they care about (if you like playing sports, you play them).
So the “problem” of poor posture is mostly minor and self-limiting. The worst problems are avoided naturally, instinctively. The postural fitness that matters the most is taken care of almost automatically. What remains is usually fairly trivial.
Doing it the hard way!
How long do you think you could work like this without regretting it?
That said, homo sapiens can also be surprisingly self-defeating! In fact, this seems to be a weird feature of “higher” intelligence.11 Human beings do not always avoid unnecessary stress. We can be surprisingly prone to doing things the hard way. So we probably do make some postural mistakes and develop bad habits, because we are careless, or our big brain is placing too much emphasis on another priority, or because don’t even know that we’re doing something wrong (like the knees-tucked-under-the-chair example). Fortunately, the scientific evidence strongly suggests that doing things the hard way, posturally speaking, is probably not all that harmful. Here are some interesting examples …
- For instance, a leg length difference is portrayed by many therapists, especially chiropractors and massage therapists, as a serious postural problem that is pretty much guaranteed to cause pain. And yet it’s been proven that people with significant leg length differences suffer from no more back pain than anyone else.12 (Not that minor differences can even be reliably diagnosed in the first place.13)
- And soccer athletes with large differences in the mass of their low back and hip muscles — exactly the kind of “imbalance” that is targeted for repair by therapists everywhere — don’t actually get hurt any more often than soccer players with more evenly distributed muscle mass.14
- Or consider this study of coordination exercises for the neck: it showed that the exercises had exactly the intended effect on coordination and posture … but no effect on neck pain at all.15 What’s the point of posture exercise if it doesn’t actually help with pain problems? Maybe none! That’s the point.
All of this flies in the face of “posturology.” That’s the cheesy, popular term for the mostly made-up “discipline” of studying the relationship between posture and pain, and even between posture and diseases.16 Posturologists (I can barely type that word with a straight face) tend to assume their own conclusion: they assume that poor posture causes pain, and then look for confirmation of that. And so there are many, many scientific papers that seem to present evidence of a connection between posture and pain, but most of them suck — here’s a nice appalling example17 — and “posturology” is mostly a slummy pseudoscientific research backwater. If posturology research was of better quality, we might actually learn something from it. But most of it must be chucked or taken with a huge grain of salt, at best.
Posture is only one of many hypothetical factors that contribute to pain problems, but in many cases it probably isn’t contributing at all. This is obvious from a simple observation: there are a lot of people with nice posture who are in terrible pain, and also many people with lousy posture but no pain.
The most stereotypical poor posture of them all — a hunched upper back, with the shoulders rolled forward — is widely assumed to be a cause of shoulder and back pain … but the assumption is almost certainly wrong. This has been studied to death (for a posture problem). According the collective results of ten different experiments it is almost certainly not a cause of shoulder pain.18 A large 1994 study of kyphosis in older women found no connection either: not even the 10% with the worst kyphosis had “substantial chronic back pain, disability, or poor health.”19 There’s just nothing there. Hunchers are just not wrecking their shoulders and backs.
More exotically, I had a truly scoliotic patient, an elderly woman with a blatant S-curve in her spine that she has had since she was a child. Despite this obvious postural stress, she suffered nothing worse than annoying back stiffness in her whole life. Another much younger woman, but with extreme scoliosis, was also amazingly pain-free.20 Meanwhile, in my ten-year career as a massage therapist, I had a steady stream of people through my office with severe, debilitating back pain … and perfectly ordinary posture. What’s the difference between these patients?
Research has shown that abnormal curvature of the cervical spine is actually not closely associated with neck pain.
Another good example: a client with a pronounced torticollis (“wry neck”), and who was even little deformed by it.21 But, once again, this middle-aged patient suffers from no more than irritating chronic discomfort, while many people with much more normal head posture are just about driven nuts by neck pain (including yours truly, which is why I wrote a book about neck pain).
There are many better-documented stories like this, like the case of a serious traumatic cervical dislocation reported in New England Journal of Medicine in 2010, notable for being mostly asymptomatic: just torticollis and stiffness, but no pain, weakness, or altered sensation. That such a serious injury could ever have that little impact on a person is quite interesting, and it puts the hazard of “poor posture” in some perspective.22 Research has shown that abnormal curvature of the cervical spine is not closely associated with neck pain23 and is probably not clinically significant.24
A particularly larger 2016 study of 1100 Australian teenagers showed that there was no correlation — none at all — between their neck posture and neck pain, contrary to all the fear-mongering we’ve heard about “text neck” in the last couple years.25 A similar 2018 study of Brazilian youths came to the same conclusion.26
For balance, I’ll acknowledge there are studies that say otherwise27 … but mostly just crappy studies in my opinion,28 and regardless they do not remotely prove that abnormal curvature actually causes pain.29
There’s no correlation between this behaviour & neck pain or headaches in teenagers.
In general, the story is the same for the low back — the other posture hot spot. For instance, you could hardly ask for a more clichéd notion about posture than the idea that slouching is bad for your back. Teens slouch a lot, and they do get back pain (though much less than adults do), so if posture is an important factor in back pain, it shouldn’t be too hard to find a connection. But a biggish 2011 study did not: “a greater degree of slump in sitting was only weakly associated with adolescent back pain.”30 No smoking gun there!
Physical therapists tend to make too much fuss over extremely subtle postural “problems,” which match up even more poorly with pain than the obvious postural problems.31 The popularity of such theories generally suggests to me that posture is often a therapeutic red herring. Both its importance and its “fixability” are routinely overestimated by professionals in a self-serving way.
And yet that doesn’t mean there isn’t still something of interest going on. Health problems don’t have to be severe to be of interest.
I enjoy “pathologizing” posture. It gives me a sense of purpose.
~ Les Glennie, Registered Massage Therapist (yes, tongue-in-cheek)
I once sat at a bar with my wife and spent about twenty minutes leaning to my right while we ate and talked, an awkward position that got uncomfortable fast. I fidgeted for a few minutes before I realized what was going on, but it was too late: my low right back had already “cramped up.” It was painful for days, and a slowly fading annoyance for weeks after that.
People with less vulnerability to body pain, especially younger people, will not relate well to that kind of story. They may be inclined to underestimate the severity of the pain, dismiss the timing as a coincidence, or to call it a problem with vulnerability rather than a postural problem. (And they may be right! More on this soon.) But it’s quite real for a great many people, especially older ones.
Hopefully I’ve already convinced you that posture isn’t exactly a critical factor in everyone’s musculoskeletal health, but I’m not throwing the baby out with the bathwater (something readers accuse me of about twelve times per week): I’ve seen countless cases where relatively obvious and avoidable postural and ergonomic stresses did seem to cause pain — and in many cases that pain was relieved easily enough just by avoiding obviously poor posture.
On the other hand, most such cases actually involved only an imposed postural stress, as opposed to “poor posture.” This is a constant point of confusion and really important to sort out …
There is a big difference between “poor posture” and “postural stress,” but the distinction seems to be absent from most discussions of posture and ergonomics.
A postural stress is a challenge to your posture that’s imposed on you, as opposed to something you’re doing to yourself out of laziness. It’s situational, as opposed to being the result of a bad habit. Some examples of postural stresses:
- trying to sleep where it’s impossible to do so without putting your neck in an awkward position, like a plane or car seat
- a cashier whose till is positioned a little too far away, causing chronic reaching
- uncorrected vision problems, forcing routine squinting and awkward head repositioning
- a drywall installer who virtually lives in constant neck extension
- a nurse who must constantly stoop over patients, and perform extremely awkward patient lifts
- a writer who must type incessantly — not a bad habit, just something that (some of us) have to do!
But sometimes you are the source of postural stress. When the challenge is self-imposed by your own positioning and readily preventable, that is poor posture.
There is some overlap between poor posture and postural stress, of course. Carrying a heavy backpack slung over one shoulder is a good example: it’s technically a self-imposed inefficient use of the tool, not an inherent flaw in the tool, and yet it’s also often convenient and sometimes temporarily necessary.
Many postural stresses are can be avoided if you recognize the problem, but
I recall a case of a man with truly awful chronic upper back pain with a nasty computer workstation. I remember my amazement as he described it to me. He was barely aware of it being a problem — I had to tease him about it, it was so absurd — but once the problem was pointed out, he made several easy improvements … and that was the end of his problem. I find it hard to think of that case as a posture case.
Another good example was the fiddle player who had developed terrible pain in his shoulder. Incredibly, he did not tell me that he was a serious fiddle player. He simply presented himself as a shoulder pain patient. It was only after carefully quizzing him that I discovered he was practicing the fiddle for hours every day with his shoulder intensely hunched up, as fiddlers do. If he stopped playing, the pain would fade away over a few days. If he resumed, it would flare back up. He had been doing this for years, but didn’t think to mention any of that to me! And what a terrible dilemma: a clear postural stress required by a beloved activity! Maybe he didn’t mention the fiddle connection because he didn’t want that to be the problem. I’m sure he didn’t want quitting to be the solution. That guy loved playing the fiddle.
Ergonomics is the science of arranging or designing things for efficient use, specifically to avoid postural stress. Unfortunately, ergonomics is usually interpreted unimaginatively, with the result that most people think that ergonomics is just about choosing office chairs and changing the tilt on your keyboard. Lots of things can indeed be said about office chairs and the tilt of your keyboard — but it’s only the tip of the ergonomics iceberg.
We live in a gravity field that never quits: day in, day out, it pulls us unwaveringly towards the center of the earth. If we are chronically crooked, some muscle somewhere is going to have to work more than its fair share to keep us upright. Try this yourself: see how long you can stand leaning a few degrees to one side. Exaggerated imbalance gets uncomfortable fast. And subtle imbalance presumably gets uncomfortable slowly, for at least some people. And the discomfort often outlasts the stress. Why?
No one really knows, but here’s a theory:
Muscle functions painlessly and well under most conditions — it’s a high-performance tissue. It can get surprisingly sensitive, though, usually in fairly well-defined patches, which are popularly called muscle “knots” or trigger points. I have written a lot about this mysterious phenomenon (including my doubts that it’s even muscular32 — but at any rate it certainly is good at seeming muscular). It’s not clear exactly what biological conditions cause this sensitivity, and it’s notoriously unpredictable. But there is one consistent method of inducing trigger point pain: awkward postures. You can provoke trigger points with a postural stress more reliably than with any other method I know of.
Trigger points seem to be closely associated with a wide variety of other common pain problems. This surprisingly ordinary condition may even be the source many of the (non-arthritic) aches and pains suffered by the human race, especially low back pain. If so, it could be costing civilization many millions of dollars in reduced economic productivity, and an even greater but unmeasurable cost to quality of life.
If poor posture contributes to the formation of knots in tired muscles — which is far from proven, but it’s a reasonable theory — then this might be the chief risk of poor posture, and it might be a good idea to try to improve it.
If it’s so easy to induce muscle sensitivity by fighting gravity and adopting awkward postures, why aren’t we all in agony all the time? Lots of people live in gravity! (Everyone but these lucky people.) And many people frequently have awkward postures, but never have pain problems.
So why me? Why so many others? And is poor posture really the problem, or are some people just excessively vulnerable? It’s probably both, but I’m skeptical about posture as the direct cause of anything. The range of asymmetry that people can tolerate is probably quite wide, highly variable, and generally narrower with age,33 but the average healthy person can probably easily tolerate “poor posture” with no problem. And if poor posture can’t really hurt a healthy person, it’s not much of a demon, is it?
On the other hand, more vulnerable people, people who get pain from trivial postural stress — people like me — do not have a posture problem so much as we have a pain problem. A vulnerability. The greater the vulnerability, the more it’s about the vulnerability and not the posture — awkward postures are just another thing that triggers pain (even if we are quite careful). It doesn’t really seem like posture is what needs troubleshooting there.
I’m a bit doubtful that anyone is wandering around in pain as they age because they were sloppy with their posture in the past. Instead, I suspect some people start to notice vulnerability to previously harmless postures … and then everyone gets there eventually. The “worst” postures become problematic sooner, of course, but I doubt they are the cause — just the messenger, and the message is, “You don’t handle physical stresses like you used to.”
All tissues wear out when the stress on them exceeds their capacity to heal and adapt. Degenerative arthritis is a universal human condition — everybody develops it eventually, to some degree. It seems like a super reasonable guess that tissues wear out unevenly when they are loaded unevenly — just like shoes wear out unevenly in proportion to how uneven your gait is.34 Some people develop arthritis much more quickly than others, and poor posture certainly is a likely suspect.
Plenty of research does confirm a logical connection between posture and arthritis. For instance, a 2012 study of knee arthritis — an ideal place to look35 — showed that people who already have arthritic knees are bigger leaners, and their gait is “consistently different” than people with healthy knees, and they probably weren’t walking differently because of pain. That is, the crookedness probably caused the arthritic pain, as opposed to arthritis just making them walk crookedly.36
On the other hand, we have all the evidence presented earlier — and much more — that janky biomechanics just generally don’t match up very well with chronic pain. Arthritis itself is often surprisingly painless. Again with the knee, one of the most popular theories in musculoskeletal medicine is that uneven control of the kneecap — due to abnormal anatomy and/or posture — will cause the cartilage on the underside of the kneecap to degenerate painfully, which in turn causes a common kind of knee pain, patellofemoral syndrome. And yet, in fact, degeneration of that patellar cartilage can be painless.37
I could go back and forth with the research all day, but the messiness of the evidence is the answer. Poor posture probably can hasten joint decay, but it’s not a major factor.
Poor posture can get us into an emotional rut. This is a more subtle postural problem: the “comfort zone” problem. (I promised not to spend too much time on it, but it does get a section.)
It’s relatively obvious that posture is shaped by mood and all kinds of other social and emotional factors. But this double-edged sword might cut the other way, too: posture may, to a modest extent, actually create and reinforce emotional states. Yes, I’m talking about “power posing” — a notoriously over-hyped idea.38 However, follow-up research has been solid enough that I feel comfortable concluding that a confident posture can influence our emotions at least a little.39 It may not be a huge effect, but it’s probably there.
If posture can influence emotions, then it’s no surprise that it could also change pain sensitivity, and there is some evidence of that too.40 So, here’s a free, easy pain relief tip at least partially based on some science: Stand tall! Assume a bold posture, a “power” posture. Or, as a mentor of mine liked to describe that posture: “Tits up!” It might actually reduce pain — a little. A temporary reduction in sensitivity is hardly a cure for chronic pain, if it works at all, but trying certainly isn’t going to do any harm.
Emotions, posture, and pain sensitivity probably do all influence each other to some degree. Most self-limiting behaviours have both postural effects and causes. The classic example is depression: a depressed person will adopt a distinctively depressed posture, which can be quite obvious to everyone around them.41 Less obviously, a depressed posture may also generate depression. Happy people who “try it on” will actually start to feel sad! And, conversely, sad people who adopt happy postures and expressions will feel a little better.
Cool, eh? Physicality and emotionality are probably not cleanly distinct!
The blending with physicality is interesting, but the emotional dimensions of posture are interesting all by themselves. Above I defined a poor posture as an “unnecessary and problematic pattern.” That pattern may be emotionally problematic. It can both express emotional hangups and actually cause and reinforce them. Posture can be a self-limiting behaviour, something that actually keeps you in a poor state of mind.
We hold ourselves in a certain ways because they reflect our comfort with the positions — and our discomfort with other positions, such as “holding our head high.” Just as we eat comfort food to our detriment, we may also slouch comfortably to our detriment, constantly projecting to the world (and creating the reality) that we aren’t ready, or we’re depressed, or sullen, or bored with life, or whatever it may be. When we leave poor posture unchallenged, we also fail to leave our emotional comfort zone, which is generally necessary for personal growth. See Pain Relief from Personal Growth: Treating tough pain problems with the pursuit of emotional intelligence, life balance, and peacefulness.
Although it’s all a bit flaky and murky, I actually believe that posture’s relevance to emotional state and pain sensitivity may be the best reason to experiment with changing posture.
To pretend to be calm is to be calm, in a way.
~ Gillian Flynn, Gone Girl
Popular thinking about posture is dominated by the ideas of straightness and alignment. It permeates even guru-level rhetoric about posture. (And just the fact that there are “posture gurus” is rather interesting, isn’t it? Why? They are gods of the gaps.42) Many posture gurus will talk about something like “an efficient response to gravity” with confidence, which is really just a fancy way of saying “straight and aligned.” I do not believe that anyone actually knows what an “efficient” posture is, and it is not necessarily defined only by straightness or precise verticality.
We are the only species on planet Earth that routinely stands upright, and there are many reasons to believe that our erectness is a biological compromise of questionable value and comfort. Scientists are not sure why we ever stood up in the first place, and there is no evidence today that standing up especially straight is necessarily the way to go … or has any survival benefit … or, if it does, that it will necessarily be comfortable …
Consider your spine. It is essentially the same spine owned by every mammal in the world. And nearly all of those mammals carry their spine horizontally. So where did we ever get the idea that we should stack our vertebrae one on top of the other?
There is no obvious sign that our anatomy has significantly or effectively adapted to the upright position. For instance, the connective tissues of our abdomen are still similar to those of the quadrupeds: they are generally suited to holding our guts suspended below our horizontal lumbar spines, not for holding them like a sack tied to a vertical pole.
Much more discussion of this idea can be found in the article Natural Imperfection.
So I reject the “stand-up-straight” definition of good posture. Good posture is not necessarily about straightness! And yet it is essentially the only widely used definition, even by people with supposedly very sophisticated opinions about posture. You may think I’m blowing the guru-thing out of proportion, but it is literally true that there have been successful entrepreneurial empires based mainly on trademarking and selling the importance of straightness and a method of getting there and staying straight, and then there are probably ten times more successul businesses that may not be devoted to posture straightening in particular, but use it as one of their founding assumptions or marketing bullet points.
I am not saying we shouldn’t stand up straight. I am just pointing out — again, in yet another way — the uncertainties associated with any idea about posture, even this most basic and universal one. There is good reason to doubt anyone who claims to know that good posture is a matter of being well-aligned.
A definition of good posture is necessarily much less precise than defining a poor posture, because it depends on what you want, and it’s essentially impossible to measure success. So here are a couple almost philosophical suggestions. I’ll let Morgan Freeman start it off …
Your best posture is your next posture.
~ Morgan Freeman
A good posture is probably “dynamic,” emphasizing change and movement. Keeping active, frequently changing our posture, and experimenting with new ways of moving through the world are probably good responses to the uncertainties of posture. It’s the same in spirit as the nutritional advice to eat a varied diet.43
Most people lead overly sedentary lives, and are overly consistent in their limited physical activity; that is, even people active at work are often active in only one way, and they need variety in their movement. More movement — not any particular position, but more positions — is definitely a safe bet and a good start on a good posture.
A variety of postural behaviours will also help to strike a balance between the path of least resistance and obsessive and excessive effort, neither lazy nor overzealous. Do not stray too far from your comfort zone, but do not linger there either.
The odds are lousy that I actually said something attributed to me.
~ Morgan Freeman
Much of what we perceive as “poor posture” is the result of biological adaption over decades and is unlikely to change without a truly heroic effort — and perhaps not even then. In principle, humans can adapt to almost anything — in fact, it’s the law.44 However, the same principle dictates that change is slow and difficult.
Wear high heels for many years, and your calves will actually shorten,45 and it’s not clear how easily that can be undone. On the other hand, grow up climbing trees like the Twa people of Africa and you will earn amazingly limber calves that allow your ankles to bend halfway (45˚) to the shin46 — two to four times greater than the average urban person! Look at them go:
“Squatting like a baby” is a faddish fitness goal — and hopelessly unrealistic for most people. But if you grow up squatting like the Hadza bushmen, it’s no problem!
As Todd Hargrove puts it, not only do these people squat like a baby, “they squat better than a baby.”
They maintained all the mobility they had as babies, but added strength, stability and skill. They never stretch, never do yoga or pilates, never engage in any corrective exercise, yet they all move effortlessly in and out of positions that most Westerners cannot even get into.
Which sounds great. But don’t think for a minute that the Twa and the Hadza don’t have their own costs and consequences for the stresses they’ve adapted so beautifully to. Everything in biology involves trade-offs.
Many adaptations are almost certainly irreversible—or so difficult that they might as well be. A child can adapt in ways that are possible only in the plasticity of a rapidly growing body, and for the adult to try to undo it is like trying to straighten wood that was once artfully bent with steam. Other changes may occur only over vast spans of time, or because of variables we have little or no control over. The result is that some adult “postures” are simply impossible to change — we really do get locked in.
And yet we can change. Stretch actually can increase flexibility, with a lot of work (more on this below), for whatever it is worth. For the office worker who feels locked into a typist’s hunch — I know I do, as I type this — isn’t it worth at least trying to break out? Is the near futility of it all the more reason to at least make the effort? Perhaps it is.
There’s no basis for “shoulding” when it comes to posture. If the only reason you want to change your posture is on principle, I don’t recommend it. It’s not worth the trouble. You are not a good candidate for this process. There are probably a hundred more useful things you could do with your time.
The cure can turn out to be worse than the disease. A bad postural habit is not unlike an addiction. Trying to live with better posture may cause more problems, or be more uncomfortable, than whatever it was that drove you to try to improve your posture in the first place.
In a short article for The Guardian, Oliver Burkeman describes what it was like to switch to a special chair that “resembles a saddle, so instead of slouching, you perch. Or that’s the idea; in reality, it’s just rather uncomfortable. After 40 minutes, it’s extremely uncomfortable.”47 Change and challenge can be uncomfortable, and the payoff is uncertain. If Mr. Burkeman were to keep that up constantly for a decade, he might “toughen up” and be a better man for it, or he might find it a wearisome strain with no clear point! Hard to call.
However, if you are driven to the idea of postural transformation because of aches and pains, you may be quite motivated by the hope of a partial solution, and the side-effects of challenging new habits may be more worthwhile. You should probably try it, and keep it up for a while to give it an adequate chance, or even just for the sake of experiment.
Try to stay interested in the challenge for at least a month. Watch and wait patiently for new developments. It took me a good six months to learn how to stop sleeping face down … but now I can’t imagine going back. People who quit trying to change their posture after a week, or even after a month, have not learned much — except that they aren’t very good at it.
Be persistent and give it a fair chance. And then, if the first honest attempt doesn’t work? Give up.
What if you give postural change a fair chance, and there are no obvious benefits? What if you can’t really tell if you’ve achieved anything? What if you still seem to be crooked? Or what if you look straighter in the mirror, but it makes no difference to how you feel?
Definitely … give up.
I am all for trying anything once, and I think postural exercise is worth a shot if you think it might be connected to a pain problem. However, if a reasonable effort fails, I do not recommend a repeat performance. Once again, there are many better things you can do with your time — not just better things in general, but better things you can do to try to solve a pain problem.
There are simply too many problems, too many questions about posture’s relevance to pain. It’s worth trying to work with posture — but it’s not worth trying a lot.
Irregularity is to be expected in any biological form. Body parts are not interchangeable legos or Ikea furniture pieces made by factory molds. Wonkiness and asymmetry are part of the plan.
~ Playing With Movement, by Todd Hargrove, p. 169
In the rest of the article, I will review some approaches to improving posture, mostly defined as “increasing postural fitness.” Whatever your approach, I recommend choosing clear, functional goals and/or solving specific problems. Rather than shooting for “good” posture, think mostly in terms of postural fitness and ask yourself: what do you want to be posturally fit for?
The example of “flexibility” is instructive: many people have a stretching habit with the specific goal of being more flexible, but they literally can’t explain why they need to be more flexible. Or, if they do, the need is trumped up, even ridiculous.48 Athletes especially tend to exaggerate their need for flexibility.49 Most people don’t need to be more than a tiny bit more flexible than they already are, if that.
Similarly, most people do not need to be posturally fit for activities that they will never actually do. You don’t need to be able to balance on a tightrope unless you plan to work for a circus. Choose goals that make sense for you. In general, goals for postural fitness are almost indistinguishable from general fitness.
The seemingly technical challenge of changing postural habits is nothing of the sort: it’s almost entirely in the realm of art and faith, not science. Measures of success are primarily subjective. I have witnessed and personally tried many tactics for changing postural habits. There are no rules, no system to which you should devote your life, no right way to do it.
But there’s probably a wrong way!
Trying to force yourself to earnestly sit or stand up straight is so ineffective and pointless that I wouldn’t even bring it up, except that … it’s actually the default approach. This is what most people do.
When people decide that they “really need to work on their posture,” they usually don’t have any clear idea what they intend to do. Most people who worry about their posture go through episodes of trying — in no particular way, just mentally straining until their discipline fades.
Posture is the product of spinal reflexes and additional tweaking by your brain, all of which occurs — as it must — without the involvement of conscious attention. While you can always exert conscious control over your posture, you will always revert to the unconscious and reflex-controlled pattern the second your mind wanders. Consciousness is really just a thin scum on top of everything else the brain does.
If you are disciplined enough, you can sustain a posture long enough that the habitual, unconscious behaviour begins to change. But such discipline may have a price that not many people want to pay. To the extent that this ever succeeds, it tends to produce rigid, artificial postures — a caricature of posture, an imitation of good posture.50
Some problems will make it particularly difficult to improve your posture. It’s a good idea to try to solve them first … if you can. Obviously in many cases it won’t be easy, or even possible.
- Fatigue, especially from insomnia. Most insomnia is behavioural and treatable, even if it seems extremely severe and stubborn. I speak from painful personal experience. Treating insomnia is the highest priority for this challenge (and practically all others).
- Pain, especially if it is actually caused by poor posture. A lot of unexplained and chronic body pain is untreatable. But some is. Common muscle pain is unpredictable, but often responsive to nearly any kind of fresh sensory input, like massage or stretching — so it’s certainly worth trying to address common aches and pains in this way before trying to improve posture.
- Mood disorders are a major barrier to postural change. I am not a mental health professional, and this is not the place to recommend any solutions for those problems. However, I have recovered (and stayed recovered) from severe depression — so I can at least say with confidence that it’s possible and relevant.
- A job with significant postural stress. By no means should everyone with a physically demanding job quit so that they can work on their posture. However, if you believe posture is an important issue for you and you have a job that makes it difficult, then you should certainly consider a change.
Doubtless there are other examples, but you get the idea: make working on posture easier. Imagine how hard it would be for someone with all of these problems: a tired, hurtin’, depressed person with a job leaning over a conveyor belt for several hours per day is probably going to have a really hard time changing postures.
That might sound pretty weird to a lot of people — okay, it is kind of weird — but you don’t have to be obvious about it. No one has to know that you’re dramatizing anything. For instance, if you find it hard to lift your chest, lift your heart instead: walk down the street pretending to be three times more confident than you are (act “as if”) and watch what happens to your chest. If your back is uncomfortably curved (perhaps an excessive lordosis), then “walk like a dinosaur” (see Tip #2) — pretend you have an enormous, heavy, swaying tail as you walk. And so on.
Todd Hargove of Better Movement:
It is usually quite obvious to people that changing their thoughts might be a good way to change their mood. For example, people might try to combat sadness or depression by “thinking happy thoughts.” Another possible approach would be to “move happy moves.”
Interrupt or remind yourself to pay attention to your goal using timers and buzzers or whatever works. This can be very useful for increasing body awareness. Similar tricks can be played with signs, alarms, or oddly placed objects around your home or office. This might seem suspiciously similar to trying to improve your posture by force of will, but my suggestion here is more just about triggering self-awareness of a specific issue. For instance, if your specific postural goal is to reduce headache frequency and severity by breaking a bad habit of sitting on the edge of your chair and leaning in too close to a computer screen … then it may be useful to remind yourself — frequently — about the problem.
Some people will relate best to an exercise ritual — strive for your goal repeatedly or continuously until it gets easier. Repetition is required for most kinds of learning. It may be useful to slightly exaggerate, as well. If you want to carry your head further back, then go for a half-hour walk every day and practice keeping your head in the “right” place, or even further back than that. Don’t worry about practicing the rest of the time, any more than you would learn guitar by carrying it around with you at all times and strumming every time you can think of it. Just set up a conscious, well-defined practice time.
Physical assistance can sometimes force the issue effectively. For instance, I don’t think that I ever would have learned to sleep on my side without the help of a pillow. To this day, I still need a pillow in my way to prevent me from rolling onto my stomach. Obviously, there is almost no limit to the creative possibilities here.
A typical example of postural taping.
If you have a specific postural challenge, such as a tendency to thrust your head forward at the computer, taping might offer you the best effort-to-reward ratio.
Taping can accomplish the same thing as discipline, but without the force of will. Simply apply medical tape — available in any drugstore — to the skin in such a way that it becomes impossible to position yourself incorrectly.
For instance, in a case of head protraction, pull your head backwards and apply a length of tape along your spine from your hairline to between your shoulder blades. The moment you try to move your head forward, you will get a nasty yank on your skin. No discipline required!
Taping is an irritating but highly effective method of forcing your postural reflexes to adapt. It is useless for more general or subtle postural degeneracy, however.
Many of the suggestions so far are just various ways of trying to “adjust your defaults” (Kabat-Zinn’s phrase) — to create a new normal state. Earlier I mentioned Oliver Burkeman’s experiment with a chair he “perched” on and how it was “extremely uncomfortable,” but he then describes an interesting change:
Now I don’t sit for too long, because it’s simply no fun to do so. After a few weeks, I realised that something intriguing had happened: I’d switched my default state. Standing or strolling was now my automatic, baseline behaviour; sitting was something I actively “did”.
Is being forced to avoid an uncomfortable chair a victory? A lasting one? Or will Mr. Burkeman at revert sooner or later to comfier furniture? My money is on reversion; I’m doubtful that his “defaults” have truly been “adjusted” (which is just another way of talking about breaking old habits and forming new ones, no more or less profound or reliable than resolutions made around January 1).
Nevertheless, it is an interesting way of trying to change your posture, or any bad habit, and probably as good as any other.
It’s a popular notion that poor posture is caused by “tight” muscles pulling on our skeletons unevenly, like pathological ship’s rigging. I recall an elaborate demonstration of this principle in massage therapy college. An instructor tied several strings to me to simulate muscles and pulled on them in various patterns to show how tightness could warp my posture. The demonstration wasn’t memorable for the reason he would have liked.51
Undoubtedly the best known specific form of this idea is that tight hamstrings cause bad posture, and therefore that stretching them will improve posture. This was specifically tested in a 2012 experiment.52 I’m afraid it didn’t work. Although hamstring extensibility was indeed improved by a fairly ordinary stretching program, it had no effect on posture. The results are probably all the more believable because I strongly suspect the researchers were hoping to prove that stretching hamstrings is good for posture, and researchers are remarkably good at finding what they hope to find. But it seems the data were just not there to exaggerate or distort.
If stretching hamstrings has no effect on posture, I doubt any other kind of stretching does either. So this is a dead end, and yet another of many examples of how stretching “works” only in the sense that it will make you a little more flexible, temporarily, but the value of that flexibility is dubious indeed. For many other examples, see Quite a Stretch.
If force of will is the worst way to improve posture, being generally physically active in a variety of ways may be the best: not only somewhat effective, but a good idea for many other reasons too, of course.
A sedentary lifestyle contributes significantly to the degeneration of postural reflexes. NASA discovered this while studying the physiological effects of inactivity. “Use it or lose it” is the unsurprising biological lesson here: organisms adapt quickly to stimuli and stresses, and atrophy quickly without them. Therefore, probably the simplest cure for eroded postural reflexes is to simply do more with your body — but nothing in particular.
While it might make sense to choose activities that are specifically challenging to your posture — and you can certainly do that if you choose (see the next section) — the spirit of this suggestion is that you can probably get decent bang for buck without focusing on posture-challenging activities. Just by doing anything you like: salsa dancing, swimming, golf, whatever. A physical challenge like paddling (dragon boating), for instance, forces you to learn how to use your upper body (very) differently. The risk is that you will simply take postural dysfunction into the new activity, but the great potential benefit is that the enthusiasm you feel for the new activity will magically inspire new habits. Many people have permanently broken old habits by taking up an exciting new activity that required being different to enjoy or succeed at.
Inspiration — not discipline!
Add some instability — manageable postural challenges — to your activities, even otherwise sedentary ones. For instance, sit on an exercise ball or a wobble cushion (a funny little balloon pillow that creates an unstable surface) instead of a chair while working at the computer.
Buy a Wobble board and stand on it … while you watch television.
If you’re lucky enough to live near a beach, walk on the sand. Sand walking and running are particularly exhausting to the postural muscles.
Many exercise activities are more obviously challenging to posture than others. Where else but in a yoga class are you going to be asked to stand on one leg? Pilates, taijiquan, dance, martial arts, even a general fitness class — all can specifically demand coordination and stability not ordinarily present in your life.
Posture is the elephant in the corner of the ergonomics room. The biggest misconception about ergonomics is that it’s about facilitating good posture. It’s much more about eliminating sources of postural stress — or it should be.
Ergonomics is the science of arranging or designing things for efficient use. Poor ergonomics not only creates direct postural stress challenges — such as reaching too high for a computer mouse — but may also force people to learn bad new habits in order to cope. Computers have made slouchers out of a lot of people.
Extremely poor ergonomic design is usually obvious, but there are many more subtle cases as well. Improving the ergonomic design of your office or home could be simple, but not every solution may be practical or affordable. For example, I frequently recommend investing in a headset for your phone so that you don’t cradle it with a tilted neck. Headset technology has become both effective and affordable, yet many people haven’t considered this solution. When you’re upgrading your ergonomics, try to think outside the box, and don’t just pick the low-hanging fruit: the best changes may require some hassle and/or expense.
I have often seen patients complain bitterly about their office chair. Being prone to aches and pains, I can’t imagine why anyone would put up with a really bad chair for more than about three days. Either the boss agrees to get you a new chair, or you go buy your own. But people balk at asking and balk at the expense. Talk about penny wise and pound stupid! It’s your back — if it’s being relentlessly irritated by a chair at work, change the chair, period, whatever it takes.
The dirty little secret of ergonomics in the workplace is that it’s usually all about making the best of a bad situation. Discussions about ergonomics routinely overlook the fact that long work days in a chair are just a fundamentally bad idea — no matter how good your chair is. Ergonomics should not be focused on ways of making people more comfortable with a bad situation — almost a conspiracy against workers — but rather on improving the situation. Conventional ergonomics, when “arranging things for efficient use” — tends to exclude the most important thing in your workstation: you!
What a perfect comic strip I found! This exactly illustrates what I’m trying to say: that conventional ergonomics solutions may be missing the point & often get out of hand.
The consequences of ergonomics that ignore you range from the irritating to the traumatic. This fascinating collection of videos of ergonomic disasters has some examples.
This section used to be a critical analysis of a specific, trademarked method and the theories of its founder, which I bought into for a while early in my career. However, his method has not thrived, and I’m not sure he’s even in the guru business anymore, so I’ve stripped out the specifics and made this section into a more anonymous, generic example. Methods like this are a dime a dozen.
This Posture Modification System (PMS) makes claims that do not have a sound scientific basis and cannot be made with the confidence that this would-be guru makes them. For instance, the website advertises that PMS “expands the fundamental concepts of physics” — language that is irrelevant to therapy. Worse, it’s grandiose and melodramatically overconfident.
The big idea of PMS is that a deviation from an erect posture can be corrected by “exercising in the plane perpendicular to the deviation.” In theory, the body “knows” that a movement in one plane — say, flapping the arms up and down — can’t be performed efficiently if you are leaning forward or backward. Hence, every flap of the arms tends to stimulate the reflex that pulls you upright.
It’s a clever notion, but it is just a notion, completely devoid of evidence. And applying the principle is not straightforward: to use it, you would need the assistance of the founder himself, or a practitioner certified in his technique (and there are not many of them). You would have to invest considerable time, money, and energy … and all based on the self-serving say-so of an aspiring posture guru.
I’m embarrassed to admit that, for several years, I taught a simplified version of PMS to my own clients. I was not always a good critical thinker — it’s something I’ve learned over the years, in part from this experience. Eventually I abandoned PMS due to its fussiness and inconsistent results. Its failure to impress me was one of the major early causes of my disillusionment with both structuralism and Modality Empires. This combination of extreme scientific uncertainty and practical challenges is a really great example of why “systems” for postural correction are so dubious.
Posture is almost certainly associated with some pain problems, but much more weakly than most people believe. Postural habits with clear consequences and easy fixes are almost unheard of. Much of so-called “poor posture” is actually just postural stress and being stuck with bad ergonomics — not really a postural problem at all. Many people seem to be unusually vulnerable to poor postures and postural stress, but these people also may not have a posture problem, but a pain problem. And many more elements of poor posture are probably the result of long-term biological adaptation that is either extremely difficult or impossible to change. About the only clear benefit to tinkering with posture is that it can affect mood, emotion and probably pain sensitivity.
Trying to change posture is probably not worthwhile for most people, most of the time. However, if you want to try it and see, your best bet is probably increased activity, especially tasks that require coordination, and especially anything you enjoy — an activity that inspires, rather than one that requires discipline. Ergonomic tuning may also be particularly helpful, especially with specific challenges. “Technical” and “advanced” methods taught by posture gurus are generally more or less wildly speculative and completely untested scientifically.
How did I make a young massage therapist cry? I told her I didn’t want to spend $1/minute on a postural “assessment.”
I was polite and nice about it, but she was one of those deer-in-headlights youngsters who probably would have burst into tears at the slightest provocation. Sort of adorably, she tried to take a professional stand: “This is what I need to do in order to do my job properly!” Insert tremulous little foot stamp. But when I continued to politely insist on getting a massage instead of standing there in my shorts hemorrhaging cash, with no conceivable improvement to my experience, the lip started to quiver and then she pretty much lost all composure. Oh dear.
And why did I do that? Joe Brence, PT, explains it very nicely: Drop the plumb line … static posture assessments were so last decade.
At that point in my career, I’d already had about a bazillion postural assessments, with every imaginable rationale … and every possible result. Although there are certain themes (yes, lookit that, my right foot does turn out, by golly), by far the strongest theme of all is that the results of postural scans are extremely inconsistent. And the idea that such “assessments” can meaningfully inform one hour of treatment is really pretty hilarious.
Some excellent comments on this topic from Facebook discussion:
Moving assessments are way less boring for everyone, and convey much more information, and still allow time for the practitioner's brain to cook up a way to begin to implement a treatment strategy/path into and through the morass that lies ahead.
Diane Jacobs, PT
Its only purpose is ritual. May as well throw some bones at them, look at how the bones land and say hmmm ominously.
Michael Reoch, RMT
I enjoy “pathologizing” posture. It gives me a sense of purpose.
Les Glennie, RMT
This article has a long, unrecorded history. It was one of the first long articles I ever wrote about health. The original version was sprawling and rambly and weird — too philosophical — but it had a lot of good ideas in it. In about 2005 or so, I decided I needed to offer my readers something more practical, and I wrote a new article focusing on reviewing exercise strategies for changing posture — but that was still an early effort, written when I was just getting started as a science writer, and it just wasn’t all that good. I updated both posture articles a few times over the years, and then finally in 2012 decided it was time for a complete rewrite. This is the result. There’s still a lot I’d like to do with it, though. Amazing how much there is to say about something that I think is “mostly much ado about nothing”!
2018 — Science update: Updated referencing and footnotes about “power posing.” [Section: What are the (emotional) risks of poor posture?]
2018 — Revision: Widespread editing related to the distinction between poor postural and postural challenge or stress. The section dedicated to that difference was completely re-written, but many other changes were made, mostly to the first few sections where I define my terms. I’ve also corrected the systematic misuse of the term “strain” when I meant “stress” (a technical but important distinction).
2017 — Science update: Added citation to good evidence of embodied psychological changes caused by non-verbal expansiveness. [Section: What are the (emotional) risks of poor posture?]
2017 — Science update: Added a paragraph about the lack of association between a hunched upper back and shoulder or back pain, with a couple good citations. [Section: Does posture matter?]
2016 — Summarized: Added a smartphone-only article summary.
2016 — Correction: A helpful reader pointed out that a 2010 study of “power poses” may not be very good science. Revised accordingly, and made a few other changes. [Section: What are the (emotional) risks of poor posture?]
2016 — Science update: Added citation about “text neck.” [Section: Does posture matter?]
2013 — New section: No notes. Just a new section. [Section: Resisting postural assessment, or how I made a newbie massage therapist cry once.]
2013 — Major new version: An all new article, really: almost nothing untouched.
- PS Your Back Is Not Out of Alignment — Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.
- PS Mobilize! — Dynamic joint mobility drills are an alternative to stretching that “massage with movement”.
- PS Ten Trillion Cells Walked Into a Bar — A humourous and unusual perspective on how, exactly, a person is even able to stand up, let alone walk into a bar.
- PS Why Do Muscles Feel Stiff and Tight? — Maybe your range of motion is actually limited, or maybe it just feels that way.
- PS Don’t Worry About Lifting Technique — The importance of “lift with your legs, not your back” to prevent back pain has been exaggerated
- It may sound strange to many readers, but many experts don’t think the idea of “poor posture” has any validity or utility at all — that there is essentially no such thing. I tend to agree, insofar as everything that is “real” about “poor posture” can probably be described just as well without using the term posture at all and avoiding all its baggage. However, I still seem some value in using the idea of posture. BACK TO TEXT
- Belief in postural dysfunction can probably drive a nocebo — the opposite of a placebo: pain caused by the belief that something is wrong — plus even more harmful spinoff beliefs about general vulnerability and fragility, and often excessive zeal for postural “correction.” I have met people who were egregious posture hypochondriacs. BACK TO TEXT
- PS Ingraham. Ten Trillion Cells Walked Into a Bar: A humourous and unusual perspective on how, exactly, a person is even able to stand up, let alone walk into a bar. ❐ PainScience.com. 2444 words. BACK TO TEXT
- And trying to change them runs you headlong into one of the most basic problems of all healing: if you were the kind of person who could readily avoid such problems in the first place, you already would have done it. Angels fear to tread here. BACK TO TEXT
- Which is no big deal — happens to the best of us. And I also suspect that Dr. Janda would have advanced his ideas along with the rest of the field if he were still with us. The man had integrity and brains. I’d like to think he wouldn’t cling to a tired old theory that hasn’t worked out, and neither should we. Rather than focusing on the wrongness, let’s focus on where the field has gone in the decades since he first defined the crossed syndromes! BACK TO TEXT
- Kneecaps evolved to jack up the leverage of the thigh muscles on the lower leg. The kneecaps push the quadriceps tendon forward, which gives the muscles a more favourable yanking angle. But there’s a price: the pressures under the kneecap reach truly astounding extremes. Even when the knee is just flexed, the pressure climbs quite high — enough to crush your finger like a walnut in a nutcracker, if you could get it in there. Sitting with your knees bent for long periods keeps the joint under that pressure. That’s a significant stress on the joint tissue that strongly correlates with the development of pain over time. It’s a perfect example of bad posture because it’s so avoidable, and because the danger isn’t obvious unless you understand knee joint mechanics and patellofemoral pain syndrome. For more information, see Save Yourself from Patellofemoral Pain Syndrome! BACK TO TEXT
- Computer gaming companies are notorious for burning out young talent, eager new coders too inexperienced to realized the danger. They “sacrifice the body” for their work, unaware of the danger. They spend long hours hunched over their keyboards in conspicuously awkward postures. Although ergonomics are a factor, mostly these are just obliviously awful postures. It is noteworthy that most of them more or less get away with it and that many of them also begin to suffer acutely. Having worked with and known many programmers, I know that a great many of them eventually become enthusiasts about posture and ergonomics. BACK TO TEXT
- Most people are at least dimly aware that sexual uptightness is a Puritan thing, that the Puritans bequeathed England and her colonies with the notion that pleasure is evil … and what’s more pleasurable than sex? (Possibly massage, and I doubt they liked that either.) Few people know that the Puritans also gave us the idea that rigid posture implies moral righteousness and strength of character. Postural laziness is a great moral failing in the Puritanical world view, which still pollutes the cultural DNA of modern civilization to a shocking degree. People still exaggerate the value of “good posture” for this reason, mostly unconsciously. BACK TO TEXT
- Many seemingly poor postures are actually perfectly good, reasonable compromises, adaptations to unavoidable stresses and challenges. Most posture nuts forget this. If the cause of a posture is baked into your anatomy, trying to change it is going to hurt more than help, or it will just be futile. If your posture is caused by adaptation to a shortened leg bone dating back to a motorcycle accident twenty years ago, you aren’t going to have much success changing your posture. The context of poor posture is important! BACK TO TEXT
- Remember, a lot of that “seeming” is just an irritating vestige of Puritan ideology. BACK TO TEXT
- A friend of mine was once a manager at factory that made window and door frames and such. He often complained about how ignorant and foolish employees were. His most outrageous example was a young man he left alone with instructions to move a palette of wood weighing hundreds of kilos. He assumed the kid would use the pneumatic cart beside the palette, but when he returned a few minutes later he found the kid sitting on the floor, red-faced, sweating, straining mightily to drag the palette by hand. Amazingly, he had actually managed to move it a few centimetres. BACK TO TEXT
- Grundy PF, Roberts CJ. Does unequal leg length cause back pain? A case-control study. Lancet. 1984 Aug 4;2(8397):256–8. PubMed #6146810. ❐
This classic, elegant experiment found no connection between leg length and back pain. Like most of the really good science experiments, it has that MythBusters attitude: “why don’t we just check that assumption?” Researchers measured leg lengths, looking for differences in “lower limb length and other disproportion at or around the sacroiliac joints” and found no association with low back pain. “Chronic back pain is thus unlikely to be part of the short-leg syndrome.” Other studies since have backed this up, but this simple old paper remains a favourite.BACK TO TEXT
- Cooperstein R, Lucente M. Comparison of supine and prone methods of leg length inequality assessment. J Chiropr Med. 2017 Jun;16(2):103–110. PubMed #28559750. ❐ PainSci #52779. ❐
Assessments of leg length are common, both with the patient lying down or standing. Either could be reliable, but in this test they did not agree with each other. Two chiropractors with more than 30 years experience each assessed the same few dozen patients, and agreement between their results when they felt confident in them was “perfectly nil.“ Despite the widespread and confident use of each method, this test clearly suggests that at least one of them is unreliable, but it’s also entirely possible that both of them are.BACK TO TEXT
- Hides J, Fan T, Stanton W, et al. Psoas and quadratus lumborum muscle asymmetry among elite Australian Football League players. Br J Sports Med. 2010 Jun;44(8):563–7. PubMed #18801772. ❐
Researchers used MRI to measure the size of kicking muscles in 54 Australian Football League players — very serious athletes, these guys, playing a very rough sport — and found that “asymmetry of the psoas and the quadratus lumborum muscles exists in elite AFL players.” Such asymmetries are widely believed by therapists to be clinically significant. Manual therapists, if they suspected such a distinct asymmetry in muscle mass, would enthusiastically and almost unanimously embrace this significant lack of “balance” as a major risk factor for injury, and a likely suspect in whatever injury or pain problem a person might happen to be experiencing.
However, the researchers also found that “asymmetry in muscle size was not related to number of injuries.”BACK TO TEXT
- Roijezon U, Bjorklund M, Bergenheim M, Djupsjobacka M. A novel method for neck coordination exercise — a pilot study on persons with chronic non-specific neck pain. Journal of Neuroengineering & Rehabilitation. 2008 Dec;5(36). PubMed #19105826. ❐ PainSci #56159. ❐
This is a quirky but dubious little study that conveniently omits a critical result from the abstract. The researchers strapped a rimmed platform to people’s heads and got them to practice controlling the movement of a ball rolling on the platform — so, basically a circus trick. The subjects (only 14 of them) ended up with less postural sway, less jerkiness in neck rotation, less fear of moving, less “disability,” and “increased general health” by various measures, all of which is mentioned in the abstract with the promising and confident-sounding conclusion that the results “support the clinical applicability of the method.” Sounds fairly good, doesn’t it? But there’s a huge gotcha: if you read the actual article, it turns out that the results involved no positive effect on pain levels whatsoever. “There was no significant decrease in VAS [pain scale] scores after the four-week training period, or at six-months follow up.” The disconnect between the results and the abstract indicate that the authors probably have a strong bias in favour of structuralism.BACK TO TEXT
- This is actually a perfectly logical extension of the pre-scientific chiropractic belief that spinal alignment is crucial to the health of organ systems. It really isn’t. See Organ Health Does Not Depend on Spinal Nerves! BACK TO TEXT
- Guimond S, Massrieh W. Intricate correlation between body posture, personality trait and incidence of body pain: a cross-referential study report. PLoS One. 2012;7(5):e37450. PubMed #22624034. ❐ PainSci #54298. ❐
The researchers looked for correlations between personality traits, postures and pain. They claim that “overall, our studies establish a novel correlative relationship between personality, posture, and pain,” but the paper is sloppy to the point of being useless. There are many red flags here. For instance, words like “overall” in that context are usually code for “we know it could be easily questioned, but in our opinion our data confirms our beliefs.” The main text kicks off with a clearly stated assumption that posture is a factor in pain. Two footnotes provided for this premise are vivid examples of particularly 13 Kinds of Bogus Citations (specifically “the curve ball” and “the backfire”). This kind of quality is generally typical of “posturology” papers.BACK TO TEXT
- Barrett E, O'Keeffe M, O'Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016 Dec;26:38–46. PubMed #27475532. ❐
This is a review of ten scientific studies of the relationship between shoulder pain and thoracic spine posture, specifically kyphosis, the slouched or “hunchback” upper back curvature widely assumed to be a cause of pain. Six of the studies were judged to have a moderate to high risk of bias. Collectively these studies produced “moderate” evidence of no relationship: that is, there’s “no significant difference in thoracic kyphosis between groups with and without shoulder pain.” One study (with a high risk of bias) contradicted the others, identifying more kyphosis in people with shoulder pain. There is strong evidence that shoulder movement is greater if you’re straighter.BACK TO TEXT
- Ettinger B, Black DM, Palermo L, et al. Kyphosis in older women and its relation to back pain, disability and osteopenia: the study of osteoporotic fractures. Osteoporos Int. 1994 Jan;4(1):55–60. PubMed #8148573. ❐
Posture is widely assumed to be a cause of pain, especially back pain, but even one of the most classic poor postures — kyphosis, excessive upper back curvature, “hunching over” — doesn’t seem to cause any trouble. In this study of 600 older women, not even the 10% with the worst kyphosis had “substantial chronic back pain, disability, or poor health.”BACK TO TEXT
- What about in 20 years? She was in her late 20s. She might well develop more serious pain. Much that doesn’t bother us in our 3rd decade of life will drive us up the wall in the 5th. Postural stresses may be very slow-motion problems. Nevertheless, her example clearly shows that it is possible to live fairly comfortably even with a major postural challenge — at least for a while. BACK TO TEXT
- This is less alarming than it sounds. His facial bones have remodelled themselves so that his eyes are level with the horizon. If he straightens his neck — which feels crooked to him — his eyes are disconcertingly lopsided! But when his neck is bent to the side, he looks and feels quite normal — just a slightly head-cocked posture. BACK TO TEXT
- Akhaddar A, Boucetta M. Dislocation of the Cervical Spine. N Engl J Med. 2010 May 20;362(1920). PainSci #55145. ❐ BACK TO TEXT
- Grob D, Frauenfelder H, Mannion AF. The association between cervical spine curvature and neck pain. Eur Spine J. 2007;16(5):669–678. PubMed #17115202. ❐ PainSci #56033. ❐
Perhaps this paper should be titled: “The lack of association between cervical spine curvature and neck pain.” In 2007, Swiss researchers examined “the correlation between the presence of neck pain and alterations of the normal cervical lordosis,” and this was probably “the first study to explicitly examine these relationships in detail.”
Many therapists assume that there is not only a correlation but a causal relationship, a classic example of structuralism. However, looking at more than 50 patients with and 50 without neck pain — a large enough study to be meaningful — the researchers found “no significant difference between the two groups could be found in relation to the global curvature, the segmental angles, or the incidence of straight-spine or kyphotic deformity.” Thus they concluded that “the presence of such structural abnormalities in the patient with neck pain must be considered coincidental, i.e. not necessarily indicative of the cause of pain.”
See also some substantive criticism of this paper.BACK TO TEXT
- Gay RE. The curve of the cervical spine: variations and significance. J Manipulative Physiol Ther. 1993;16(9):591–4. PubMed #8133194. ❐
This review of several papers about neck posture indicates that “a wide range of normal exists in the posture and configuration of the cervical spine,” and concludes, “There is little evidence to support the contention that altered cervical curvatures are of prognostic significance.”BACK TO TEXT
- Richards KV, Beales DJ, Smith AJ, O’Sullivan PB, Straker LM. Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents. Phys Ther. 2016 May 12. PainSci #53482. ❐ “The finding of no association between cluster membership and neck pain and headaches challenges widely held beliefs about the role of posture in adolescent neck pain.” BACK TO TEXT
- Damasceno GM, Ferreira AS, Nogueira LA, et al. Text neck and neck pain in 18-21-year-old young adults. Eur Spine J. 2018 Jan. PubMed #29306972. ❐
This study of 150 young adults found no link between neck pain and poor posture while texting, so-called “text neck.” The possibility of a link emerging over many years of text-neck posture has yet to be investigated, but this suggests that any long term link is probably minor, or there would be at least some detectable short-term link.BACK TO TEXT
- McAviney J, Schulz D, Bock R, Harrison DE, Holland B. Determining the relationship between cervical lordosis and neck complaints. J Manipulative Physiol Ther. 2005;28(3):187–93. PubMed #15855907. ❐
Researchers examined 277 neck x-rays and reported a “statistically significant association between cervical pain and lordosis < 20 degrees” — in other words, painful necks tended to be flattened necks (about 10 degrees flatter than the lower end of what they defined as normal). They concluded that “maintenance of a lordosis … could be a clinical goal for chiropractic treatment.” A cynic might point out that the authors were chiropractors, and the odds that they would identify a justification for chiropractic therapy in the data were approximately “very high.” (It is also unclear and implausible that chiropractic treatment is capable of achieving the clinical goal of “maintenance of lordosis.”)BACK TO TEXT
- Studies like McAviney et al are a dime a dozen. You can easily find more like it. Their shoddiness only reinforces the point — the only studies that are “finding” a clear, important connection between posture and pain problems are the sloppy, self-serving ones. Ergo, there probably is no clear, important connection. BACK TO TEXT
- It is entirely possible that pain alters posture — indeed it’s rather likely (see Hirata et al). Simply showing a correlation between a postural pattern and pain does not really tell us anything except that they have “something” to do with each other. BACK TO TEXT
- O'Sullivan PB, Smith AJ, Beales DJ, Straker LM. Association of Biopsychosocial Factors With Degree of Slump in Sitting Posture and Self-Report of Back Pain in Adolescents: A Cross-Sectional Study. Phys Ther. 2011 Feb. PubMed #21350031. ❐ BACK TO TEXT
- PS Ingraham. Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain. ❐ PainScience.com. 18225 words. . BACK TO TEXT
- PS Ingraham. Trigger Point Doubts: Do muscle knots exist? Exploring controversies about the existence and nature of so-called “trigger points” and myofascial pain syndrome. ❐ PainScience.com. 11998 words. People experience muscle pain and acutely sensitive spots in muscle tissue that we call “muscle knots.” What’s going on? The dominant theory is that a trigger point is basically an isolated spasm of a small patch of muscle tissue. Unfortunately, trigger point science is half-baked and controversial, and it’s not even clear that it’s a “muscle” problem. Meanwhile, people keep hurting, and massage — especially self-massage — is a safe, cheap, reasonable way to try to help. That’s why I have a large tutorial devoted to how to self-treat “trigger points” — whatever they really are. BACK TO TEXT
- Apply the leaning test above to a teenager and grandmother: who lasts longer? BACK TO TEXT
- That phenomenon can be very pronounced. I have seen shoe soles nearly destroyed on one edge, and pristine on the other. I assume that something similar is going on inside joints: they are more resilient than shoes, but they obviously aren’t impervious. BACK TO TEXT
- Knees are the most arthritic joint in the body, and also one the most likely to be vulnerable to posture. This in itself is an interesting clue. BACK TO TEXT
- Bechard DJ, Birmingham TB, Zecevic AA, et al. Toe-out, lateral trunk lean, and pelvic obliquity during prolonged walking in patients with medial compartment knee osteoarthritis and healthy controls. Arthritis Care & Research. 2012 Apr;64(4):525–32. PubMed #22213740. ❐ Causality is a major problem with studies like this: it utterly lacks the scientific power to actually demonstrate causality. Nevertheless, I like that the authors actually considered the problem (too many researchers ignore it), and I do agree with their conclusion: “over 30 minutes of walking, these gait characteristics remain quite stable, suggesting they are not acute compensatory mechanisms in response to repetitive loading with subtle increases in pain.” That’s good thinking, I think. BACK TO TEXT
- Dye writes, “ … certain individuals essentially are symptom free despite the presence of overt, radiographically, and scintigraphically [x-ray and bone scan] identifiable advanced degenerative changes of the patellofemoral joint.” There’s a lot more detail on this topic in my PFPS tutorial. BACK TO TEXT
- Carney DR, Cuddy AJ, Yap AJ. Power posing: brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychol Sci. 2010 Oct;21(10):1363–8. PubMed #20855902. ❐
This famous paper presents the original evidence that “power posing” will not only make people feel more powerful but also cause some hormonal changes: more testosterone, less cortistol (stress hormone). This was the inspiration for one of the most popular TED talks of all time, and subsequent studies conspicuously failed to replicate their results. There probably is a power-pose effect, just not a dramatic one (see Gronau 2017).
(See more detailed commentary on this paper.)BACK TO TEXT
- Quentin F. Gronau, Sara Van Erp, Daniel W. Heck, et al. A Bayesian model-averaged meta-analysis of the power pose effect with informed and default priors: the case of felt power. Comprehensive Results in Social Psychology. 2017;2(1):123–138. PainSci #53062. ❐
Carney et al infamously reported that “power poses” not only made people feel more powerful and daring, but that they had a biological fingerprint: more testosterone and less cortisol (stress hormone). And then the trouble started: “these power pose effects have recently come under considerable scrutiny,” which is a bit of an understatement: there have always been strong concerns about both the science itself and the way it was presented (premature hype).
This meta-analysis took a crack at producing the “last word” on this topic. It was part of a special edition of Comprehensive Results in Social Psychology, in which Carney herself was deeply involved (see CRSP special issue on power poses: what was the point and what did we learn?). It concluded that follow-up evidence for the original finding was “very strong,” and yet with a spectacular hold-your-horses caveat: “when the analysis is restricted to participants unfamiliar with the effect, the meta-analysis yields evidence that is only moderate.”
Translation: belief in the power of power posing will make you feel more powerful than power posing itself! Expectations seem to be the more potent active ingredient.
“Expansive postures” probably do make people feel more powerful … but only a little. Unless you believe in them, in which case you’re really off to the races. Which is fine. (“Why not both?”)BACK TO TEXT
- Bohns V, Wiltermuth S. It hurts when I do this (or you do that): Posture and pain tolerance. Journal of Experimental Social Psychology. 2012 Jan;48(1):341–345. PainSci #54508. ❐ BACK TO TEXT
- Richards KV, Beales DJ, Smith AJ, O’Sullivan PB, Straker LM. Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents. Phys Ther. 2016 May 12. PainSci #53482. ❐ Cited above with regards to “text neck,” this study of 1100 teens also found that “Those classified as having slumped thorax forward/head posture were at higher odds of mild, moderate or severe depression. Those classified as upright posture exercised more frequently.” And more frequent exercisers are quite unlikely to be depressed. BACK TO TEXT
- “God of the gaps” is an expression from atheism and skepticism. It refers to the way the idea of gods has always been used to fill in gaps in human knowledge: whatever we can’t explain in the universe is attributed to one god or another. “Gurus” are like little gods of little gaps in health care knowledge: they exploit areas of mystery in life (and medicine), selling the appearance of answers in an area where there really aren’t many answers, if any. Posture is clearly a murky subject. Therefore there are gurus for it. This isn’t always a bad thing — it can be nice to have a thoughtful guide in the wilderness of knowledge — but usually it is. BACK TO TEXT
- Interestingly, it’s not clear that a varied diet is all that it’s cracked up to be: there are many interesting examples of people thriving on amazingly boring and simple diets. And neither is it clear that a lot of miscellaneous activity makes much of a difference to posture. Perhaps someone could make a case for meditative stillness being the key to good posture! However, in both cases, variety is probably just a sensible gamble, because it is at least safe, if not important. BACK TO TEXT
- Wolff’s law and Davis’ law. There are two “laws” of tissue adaptation, one each for hard and soft tissue: Wolff’s law covers bone, but Davis’ law for soft tissue — muscles, tendons, and ligaments, fascia — is relatively obscure and imprecise. Many treatments are based on the idea of forcing adaptation or “toughening up” tissues. It has always been a reasonable idea, but what’s the “right” amount and kind of stress? Results vary widely. See Tissue Provocation Therapies: Can healing be forced? The laws of tissue adaptation & therapies like Prolotherapy & Graston Technique. BACK TO TEXT
- Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol. 2010 Aug;213(Pt 15):2582–8. PubMed #20639419. ❐ PainSci #55265. ❐
High heels are often vilified, but this carefully done 2010 study showed that the body adapts effectively and minimally, producing quite similar functional results. The most interesting implication of their results is simply that “muscle structure may adapt to a chronic change in functional demand” — which might seem obvious, but that little bit of science has been hard to nail down over the years, and this is a good piece of the puzzle.
Chronic heel wearers do have shortened calf muscles, stiffer Achilles tendons, and a smaller ankle range of motion, but these changes “seem to counteract each other since no significant differences in static or dynamic torques were observed.” In other words, high heel wearers are not progressively disabled: their ankles work fine, just differently. This doesn’t mean there’s no conceivable harm (for instance, Kerrigan found evidence of harm to the knees), but it does tend to downgrade concern on the topic.BACK TO TEXT
- Venkataraman VV, Kraft TS, Dominy NJ. Tree climbing and human evolution. Proceedings of the National Academy of Sciences of the United States of America. 2012 Dec. PubMed #23277565. ❐ PainSci #54672. ❐ BACK TO TEXT
- The Guardian [Internet]. Burkeman O. This column will change your life: adjust your defaults; 2012 Dec 22 [cited 14 Nov 27]. BACK TO TEXT
- I corresponded with a golfer recently who was convinced that stiff hip flexors were holding him back, despite the fact that he already had normal, healthy hip joint range of motion. His seriousness of purpose was equalled only by his ignorance of anatomy and kinesiology. He was just a bimbo of a golfer, obsessed with anything that might give him an edge. BACK TO TEXT
- Flexibility in itself conveys no performance benefits to most athletes, unless flexibility is specifically necessary (i.e. gymnastics). Indeed, there is decent evidence that pre-event stretching actually impairs performance! See Quite a Stretch. BACK TO TEXT
- I have come across only a handful of people who seem (or claim) to have “corrected” posture by force of will: that is, through vigilant attention to standing up and sitting up straight. Unfortunately, in all such cases, not only was it unclear if they had solved any problem that needed solving in the first place, but the cure was quite possibly just as bad as the disease: a chronic and substantial rigidity extending through habits of both body and mind. These were tense, uptight people, working hard instead of smart, and there are almost certainly better ways to stand up straight. BACK TO TEXT
- It was a ridiculous oversimplification to make an pointless point! The demonstration was not contrived to illustrate anything that’s actually known in biology and kinesiology — it was just a dramatization of a trumped up self-serving justification for doing massage therapy! And stretching. BACK TO TEXT
- Muyor JM, López-Miñarro PA, Casimiro AJ. Effect of stretching program in an industrial workplace on hamstring flexibility and sagittal spinal posture of adult women workers: a randomized controlled trial. J Back Musculoskelet Rehabil. 2012;25(3):161–9. PubMed #22935854. ❐ BACK TO TEXT