Why Research Gets Posture vs Pain Wrong
Key insights: 60-second read
- Research alone doesn't tell the whole story - Evidence-based practice combines research with clinical experience and patient experience. All three have potential for bias, so we can't just let research alone dictate what we do - it has to be supported by the other two facets as well.
- Poor posture is a terrible predictor of pain - But once you are in pain, hindsight is perfectly clear. The shapes you spend the most time in often line up perfectly with where your dysfunction occurs.
- Better posture equals better performance - Even if posture doesn't predict pain, it does predict function. Slouching reduces shoulder range of motion and lung capacity by measurable amounts.
- Two simple tests can reveal your hidden issues - Use a ball to find hidden spinal stiffness, then compare that to the shapes you hold most during your day to understand your unique connection between posture and pain.
Does good posture matter? Can bad posture cause pain? These are questions that have become surprisingly controversial in recent years.
You may have heard people say that "research shows no link between posture and pain." And if you read certain studies, that can certain appear to be true. But what if that perspective is missing some crucial context?
In this article, I want to give you a respectful, considered, and contextual summary behind why posture does matter - based on the video below, and why it may have a very tangible and observable link to any aches, pains, or injuries you may be experiencing. I will also show you two simple diagnostic tools you can use today to better understand how your daily shapes and postures might be influencing any dysfunction you may be experiencing.
On this page
1. Research vs Evidence-Based Practice
Before we can challenge the view that there is no evidence supporting a link between poor posture and pain, we need to provide a little context around evidence-based practice and how research fits in.
One of the biggest issues I see in healthcare, medicine, and how the general public thinks about research is that for some reason, we use research as the sole piece of evidence to support something. As a physiotherapist in a profession that values evidence-based practice, it is important to make a very strong distinction between research and evidence-based practice.
While they may appear to be the same thing, what often gets lost in this thirst for evidence is that evidence-based practice absolutely includes research, but it shares equal footing with clinical experience and patient experience to give us the best understanding of what the evidence means.
What This Means For You
If a research paper suggests there is no meaningful link between posture and pain, but your therapist's clinical experience or your own personal experience tells you otherwise, both perspectives are valid. The best approach is to consider all three pillars of evidence-based practice together - not to dismiss one in favour of another.
2. Why Research Alone is Limited
One of the main limitations of research in general is its ability - or inability - to be generalised to a wider population than the study was conducted on.
When I studied physiotherapy at university, we were educated on an organisation called PEDro. PEDro is an organisation that indexes tens of thousands of physiotherapy-relevant research articles and measures them up against 10 criteria that look for bias within those studies.
PEDro uses their scale to give each study a rating out of 10, with 10 being no biases found and zero being all biases found. You may be surprised to know that the average PEDro score is not an 8, 9, or 10 out of 10. It is about a five or a six. What this suggests is there's a decent potential for bias in the studies that help shape our thinking about any particular topic - let alone the effects of posture on pain.
This is not to say that every study looking into posture and pain is biased or not a good study. But the concept of research and how much we value the conclusion of a research paper may not give us all the context we need to be able to generalise the results to you in the real world.
If a study is correct, and even if there are biases in the study, the results of that study should line up perfectly with what we find clinically and what you find as a person. If it doesn't then perhaps those biases become more important - if not something else. But for me, clinically, the shapes and positions that you put your tissue in the most do have a very tangible, logical, and valuable connection to pain and dysfunction. I just don't have good quality research to back this up, yet.
3. The Real Relationship Between Posture and Pain
So, if posture and pain are linked, why do some studies suggest they're not?
I do agree that it's relatively hard to link poor posture with pain as a predictive model. The main reason for this is that we are dealing with pain - a highly complicated, complex, multi-factorial, holistic phenomenon that is inherently different for every single person.
Similarly, to say that poor posture leads to pain is far too simplistic. It does not take into account things like tissue robustness, strength, body mechanics, stress, how you sleep, what your diet looks like, genetics, and what the rest of your life looks like. All of these things can play a meaningful role in getting your body to the point where your brain and your tissue breaches its threshold for pain.
Key Concept: The Threshold Model
Pain is your brain and nervous system's perception of threat. The moment you tip over that threshold is the answer to an algorithm that takes into account literally everything you have been through in your life.
Some people can have less than ideal posture their entire life and never get to that point where their posture tips them over the threshold. The makeup of their life, their tissue quality, their exercise habits - the positive versus negative balance - may never tip them over the edge.
This is why it is reasonable to say that poor posture may not matter for some people. But if someone develops pain and the balance shifts enough that they're now above that threshold, when we are looking to understand what has led them down this path, we cannot permanently fix the dysfunction without having a conversation about how they hold and position their tissue the most during the things they do the most throughout the day.
For most people, that is sitting. And once we layer over the top of that the shapes and positions they get into the most, the location of their dysfunction almost always lines up perfectly with where they lose their good shapes and postures when they are doing the things they do the most.
4. Posture Affects Function
While it is hard to associate bad posture with pain, it's not hard at all to associate bad posture with bad performance. If we take pain off the table and just look at what allows your body to function the best, good posture gives you the best access to the function of that tissue.
There are two really simple tests you can do right now to understand what I mean by this:
Test 1: Shoulder Range of Motion
- Get into a really slouchy posture. Do whatever comes naturally to you.
- With your elbows straight, lift your arms up as high as you can go. Notice where you run into the end of your shoulder function.
- Now sit up nice and tall with your shoulders comfortably back.
- Repeat the same arm raise. You should find you have access to your inherent shoulder range to whatever degree you still have available.
Test 2: Breathing Capacity
- Slouch and relax as best as you feel comfortable.
- Try and take as deep a breath as you feel you can. Take note of how much air you feel you can get into your lungs.
- Now sit up nice and tall with your shoulders back.
- Repeat the same deep breath. You should feel like you can get about 20-30% more air volume into your lungs.
If you are someone who values running, swimming, cycling, or anything where oxygenation and lung volume is important, one of the lowest-hanging fruits you can improve upon is working on improving the position that your lungs are in.
None of this may suggest that being in a bad posture will lead to injury or pain - again, it is hard to predict. But if you have genuine dysfunction and you are not looking at the shapes and positions relative to that dysfunction, you may never get to the root underlying cause of why you have this dysfunction in the first place, or why it is hanging around and not going away.
5. Two Diagnostic Tools to Try Today
Here are two simple diagnostic things you can do to better understand any potential connection between the shapes and postures you get into day-to-day and any pain, injury, dysfunction, or poor performance you may be experiencing.
Tool 1: The Ball Test
Take a tennis ball or a lacrosse ball and use it to go hunting through your spine for any joint stiffness or muscular tightness.
How to Do It
- Start by placing the ball in the middle of your upper back, just to one side of the spine.
- Lean back into the ball against a wall.
- What you are looking for: You are not just looking for anything that feels painful or sore. You are looking for something that feels stiff, tight, hard, and restricted when compared to the other side - which may feel softer and more supple.
- Work your way up and down the spine, side to side.
- Make a mental note of exactly where you feel these restrictions.
The reason why this is important is that not only can you spend some time on the ball freeing up and releasing restricted tissue, but you can take this information and compare it to our second diagnostic tool to better understand why it has become stiff, tight, and restricted in the first place.
Tool 2: The Posture Awareness Test
The second diagnostic tool is understanding what your best posture or position feels like, and then being able to compare that to all the main shapes and positions you might get dragged into unknowingly the most throughout your day-to-day life.
How to Do It
- Stand up nice and tall with your shoulders comfortably back. Imagine someone has grabbed you by the top of your head and is pulling you straight up.
- Now, sit down on the chair you use the most. Try to maintain that same tall, upright shape.
- If you know that this is a great position for you, anything that drags you out of this shape and keeps you there for any meaningful length of time is what we are interested in.
- Pay attention to where you lose your good posture - is your desk too low? Are your keyboard and mouse too far away? Are you looking down at a screen?
- Now, overlay the location of your ball test restrictions onto the shapes you hold most during the day.
The Connection
What I find clinically is that where you may be losing your good postures and shapes is exactly where the load is going for the entire time you are doing the things you need to do. The location of your spinal stiffness from the ball test will almost always line up with where you are being dragged out of your best position throughout your day.
It can be hard to mount a case that poor, prolonged, static positions have a direct influence on pain and injury. But if we take pain off the table and make these logical connections between where your dysfunction is and how you load up those areas day to day, and then bring pain back in over the top at the end of that conversation, clinically this is the main reason why I have come to understand that the postures and shapes you get into the most throughout the day are the most meaningful piece of the puzzle.
Your posture does matter. Whether it matters to you in the context of pain, or it matters to you in the context of better sports performance or even just improved quality of life, it is genuinely unreasonable to expect to go dysfunction-free if you are not giving your body the best chance to do so.
It is also important to mention that it is unreasonable to hold yourself in a "perfect" position all day. If you have to sit for longer than you feel you can tolerate actively holding a position, we still need to value the concept of keeping your back in a neutral position. Use a rolled-up towel or a cushion to fill the gap that your back would otherwise want to fill if you were to slouch and relax. Use that device to make it easier for you to be held into a better position for longer.
I hope that this conversation has given you a respectful, measured, and logical perspective on why posture does matter. This is a conversation I face a lot as a physiotherapist - not necessarily with my patients, but more so on an intellectual and academic basis where people are comfortable challenging the idea that posture matters in pain and dysfunction.
- Grant
Frequently Asked Questions
Does research show that posture causes pain?
Research generally shows that poor posture is a poor predictor of future pain. However, this does not mean posture is irrelevant to pain. Once you are in pain, the shapes and positions you spend the most time in often line up perfectly with where your dysfunction occurs. The limitation is that research alone cannot capture the complexity of pain, which is why clinical experience and patient experience are equally important.
Can poor posture affect my breathing?
Yes. If you slouch and then sit up tall, you will likely find you can take a deeper breath when sitting upright. Many people can get 20-30% more air volume into their lungs simply by improving their sitting posture. This can be particularly important for people who value endurance sports or who have respiratory conditions.
What is the best sitting posture?
Your best sitting posture should ideally be the same as your best standing posture - up tall with your shoulders comfortably back. In a perfect world, your best standing posture and your best sitting posture would not be different, because it is the same tissue. Use a rolled-up towel or cushion to fill the gap behind your lower back to make it easier to maintain this position for longer.
Is there a link between posture and performance?
Yes. If you take pain off the table, poor posture is very clearly associated with poor performance. For example, a slouched position reduces shoulder range of motion and lung capacity. Better posture puts your tissue in what is called "anatomical position," which is universally agreed upon in medical textbooks as the shape that the human body expresses itself best within.
How can I tell if my posture is causing my pain?
Try the two diagnostic tools described in this article. First, use a ball to find hidden areas of spinal stiffness and restriction. Second, pay attention to where you lose your good posture during the activities you do most throughout the day. If you overlay these two findings, you will likely find that where your restrictions are is exactly where you are being dragged out of your best position most often.
One key insight from this video
"Poor posture is a terrible predictor of pain. But once you are in pain, hindsight is perfectly clear. The shapes you spend the most time in throughout the day line up perfectly with where your dysfunction occurs."
Have Posture-Related Pain?
If you are experiencing pain that you suspect may be related to your posture or daily shapes, we can help. Learn more about our physiotherapy services in Port Macquarie.
Want personalised guidance?
If you would like help making sense of your aches, pains, or ongoing symptoms, you can book with Grant either in Port Macquarie or via an online telehealth consultation.
