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The Science Behind Why Assessing And Blaming Posture For Pain Is B.S.

If I had a £ for everybody that mentioned posture on social media or when they had a pain problem…… well lets just say I would be a pretty rich guy.

POSTURE has literally become engrained in peoples thoughts when talking about back, shoulder or neck pain even though we have a shit ton of studies that compare the postures of pain-free people with those with back, shoulder or neck pain and find no real differences, this information gets regularly IGNORED.

NEVER let science get in the way of a good story, especially if it’s on the interwebs!

In fact, I have written about posture a few times before:

The definitive guide to posture and pain 3 minutes flat

Do you really need your joints to be centred?

But just to kick off with a bit of science, this paper HERE from 2016 found NO significant difference in lumbar lordosis (spinal curve) between people with back pain and those without.

This is super important. HOW can we blame something that we see in people WITHOUT pain as a cause of pain for those that do?

I will just let that sink in…

What Are You Measuring?

In this blog, we are going to explore a few questions related to how we assess posture and if they are actually scientifically VALID, because if you don’t have a good measure, to begin with then it is pretty tough to blame something for the problem.

The first piece of ACTUAL EVIDENCE, something often missing in the posture debate, looks at the measurement of STANDING LUMBAR LORDOSIS (the curve in the back often blamed for back pain) and this assessment is something that is performed in treatment rooms and gyms the world over.

The idea is that an increase (and sometimes decrease) in lumbar curve increases back pain and is often coupled with the idea that the tilt of the pelvis has an influence on the size of the lumbar curve, even though lumbar curves do not seem to be much of a factor in lower back pain anyway (see the SCIENCE above : )

Way back in 1990 this was explored by Heino et al HERE and they found that the angle of someones pelvic tilt and their lumbar curve do not simply correlate! So looking at the position of the pelvis tells us very little about what is occurring at the lumbar spine, which is much harder to measure. A very similar study HERE from before this in 1987 also threw up the same result but this BS is still being taught today.

Anyway, back to the standing measurement paper HERE. The authors explored the variability in standing posture of 400 people, 332 without pain and 83 with low back pain, and they found that each time we stand we do it in a slightly different way.

The authors in their words state standing is highly individual and poorly reproducible”.

So why does this matter?

Well simply put, which posture are you ACTUALLY measuring with your postural assessment. One may show an increase in lordosis, another less so.

I have some questions related to how we interpret postural assessments in light of this information.

  • Which of these postures is related to the problem?
  • How many times do you measure and do you average?
  • What are you comparing against to determine if the curve is too much or not enough?

The authors highlight a good point that the lack of consistency in standing posture may actually lead to the “wrong diagnosis and possibly unnecessary treatment”.

If you focus on something that is not an issue you do not focus on something else that might be or be blinded to the fact that it is not working or only works transiently (potentially why so much back pain is persistent).

What people actually use in their everyday lives might also be different to what is measured in the clinic or gym. A clinic or gym measure could be described as a ‘snapshot’ and this study HERE compared this ‘snapshot’ to what was actually used on a daily basis by the study participants.

The authors found that on average whilst standing, as most postural assessments are, there was a 33.3° lumbar lordosis but the average used over a 24hr period was only 8°, a huge difference!

So the ‘snapshot’ postural assessment would not really inform us very well about how much lordosis was REALLY being used and we could overestimate the extent of the imaginary problem.

We also have to remember these were radiological measurements and this is the clinical ‘gold standard’. Often a lordosis is measured in a much more rudimentary fashion by looking at the relationship of landmarks at the pelvis indicating a pelvic tilt and therefore change in the lumbar curve, which we have already discussed as not being well related to lumbar curve! This in itself is a problem as demonstrated by Preece in 2008 HERE as pelvic morphology is also VARIABLE leading to incorrect measures.

These results suggest that variations in pelvic morphology may significantly influence measures of pelvic tilt and innominate rotational asymmetry”

 Here is the distribution of side to side difference of the ASIS-PSIS relationship (used to assess pelvic tilt), we can see it is skewed to the right side meaning it is more anteriorly tilted at a BONY level.

Jmmt0016 0113 F04

So it might be that we are really bad at measuring something that doesn’t matter that much. OUCH

Are You Biased?

Another important question for those that assess posture is…are you MORE inclined to see an ‘abnormality’ in posture when you know pain is present?

This paper HERE would suggest so. Here the authors looked at scapular dyskinesis or abnormal posture and movement of the shoulder blade, which is often proposed as a CAUSE of shoulder pain.

They compared 67 people with shoulder pain and 68 without and firstly found that there was no difference in shoulder posture or motion between those with pain and those without.

Fascinatingly though when the assessors were aware that they were assessing someone IN PAIN, they reported a greater prevalence of a postural or movement problem. This shows a bias towards finding an ‘abnormality’ to blame when there is pain, even though there was NO MORE ‘abnormality’ in those with pain than without.

The authors also suggest that scapular dyskinesis actually represents normal variability between humans! Perhaps if they assessed it multiple times it would throw up different measures each time?! It is important to remember we have no scientifically defined ‘good posture’ to base deviations from in the first place.

How Do Healthy People Sit?

Another question is how do people without back pain actually behave? They must have great daily posture, right? Well actually NO.

This paper HERE shows that asymptomatic folk, 50 of them, when seating actually SLUMP. In 10-min sitting, spinal angles flexed 24 deg at lumbar and 12 deg at thoracolumbar regions relative to a standing posture. But this slumping does not seem to cause them problems.

So changes in our spinal curves seem to be fairly unrelated to pain as we can see below.

 

PowerPoint Presentation

 

So If Posture Does Not Really Correlate With Pain, What Does It Correlate With?

Well, this paper HERE shows that cervical spine alignment changes actually correlate with age. This study split the participants into 4 groups determined by age. They found that the measures of the angles of the neck all correlated with the increasing age range of the 4 groups.

The key point to remember here is that all the participants, 120 of them, had no pain. In fact, the exclusion criteria here was pretty rigorous and the authors actually excluded 64 people, so 1/3 of the original sample, for having current or previous pain.

So simply put, as we get older our posture becomes ‘worse’ or perhaps better put our posture increases….BUT and a this a big BUT, this does not seem to cause MORE pain.

To sum up it does not seem as simple as ‘bad’ posture = pain whatever you read or are told in a bar, gym or clinic room.

Key Take Homes

  • People IN pain DON’T have different postures to those that don’t have pain
  • Posture displays variability just like movement
  • This means your assessment may not tell you what you think it does
  • Your assessment could be biased to finding a postural ‘problem’
  • Postures used throughout the day are probably different to those being assessed
  • As we get older our posture change and this happens to people NOT in pain too

Articles Of The Week December 10, 2017

 

Great article about pain and why we experience it. One of the great things about this article is that while we are becoming more aware of pain science in massage therapy, not all industries are as aware of the new research. So Elie Somers is bringing it to the strength training industry.

“What Is Pain And Why Do We Experience It” – Elie Somers

As we all heard about the Massage Envy stuff last week, there were blogs everywhere writing about it. But I found this one especially interesting. Is it possible that the Massage Envy debacle is our fault?

“An Open Letter To The Massage Therapy Profession: Massage Envy Is Our Fault” – Lauren Cates

There are many facets to our massage therapy and business. One facet is our massage schools and education. Apparently, some organizations expect schools to show up and have their students provide free work. But is this right, or should everyone have to pay for students to provide massage?

“Free Student Chair Massage? Nope!”  – Jill Berkana

I liked this one because there is a lot we can liken to being massage therapists. While our scope is different, there is a lot Paul is saying in this post we could look at as well. There is so much massage therapy can do to be part of healthcare, but WE have to evolve and develop in order to be looked at that way.

“Physiotherapy, Come Forward! (It’s Time To Step Out From Behind The Curtain)”  – Paul Lagerman

How is the culture in your clinic? Is it an open and psychologically safe place where comments and new ideas are easily presented? While it’s intended for companies with employees, this is something that could be applied in our clinics as well to create a culture of psychological safety.

“How To Create A Culture of Psychological Safety” – Jake Herway

 

Why Do Muscles Feel Tight?

*This was originally published on Todd Hargrove’s blog Oct 12, 2016

Why do muscles feel tight? Does that mean they are short? That they can’t relax? And what can you do about it?

Here are some of my thoughts about why muscles feel tight and what to do about it.

(Update – See bottom of the post for recent research confirming some of the speculations in this post.)

Tightness Is A Feeling, Not Just A Mechanical Condition

When someone says they feel tight in a particular area, they might be referring to several different complaints. So I try to find out:

  • Are they talking about poor range of motion?
  • Or maybe range of motion is fine, but a movement to the end range feels uncomfortable or takes excess effort.
  • Or maybe the problem isn’t really with movement, but just that the area never reels feels relaxed.
  • Or maybe the area feels basically relaxed, but has some vague sense of discomfort – a feeling that is unpleasant but too mild to be called pain.

This ambiguity means that the feeling of tightness is just that – a feeling – which is not the same thing as the physical or mechanical property of excess tension, or stiffness, or shortness. You can have one without the other.

For example, I have many clients tell me their hamstrings feel tight, but they can easily put their palms on the floor in a forward bend. I also have clients whose hamstrings don’t feel tight at all, and they can barely get their hands past their knees. So the feeling of tightness is not an accurate measurement of range of motion.

Nor is it an accurate reflection of the actual tension or hardness of a muscle, or the existence of “knots.” When I palpate an area that feels tight to a client (let’s say the upper traps), they often ask – can you feel how tight that is?! 

I often say something like:

Ummmmmm …… no. It feels just like the surrounding tissues.

But I completely understand that it FEELS tight in this area and you don’t like it.

I don’t like the feeling of tightness either so I want to help you get rid of it. But the feeling of being tight isn’t the same thing as that area actually being physically tight. Make sense?

This actually does make sense to most people, and they find it mildly interesting. I want people to understand this because it might help them reconsider a misconceived plan they may have already developed for curing their tightness – such as aggressive stretching, fascia smashing, or adhesion breaking. So now they are willing to consider an approach that is a bit more subtle than driving a lacrosse ball halfway through their ribcage.

Why Do Muscles Feel Tight If They Are Not Actually Tight?

So why would a muscle feel tight even if it physically loose?

I think we can use pain as an analogy. Pain can exist even in the absence of tissue damage, because pain results from the perception of threat, and perception does not always match reality. Pain is essentially an alarm, and alarms sometimes go off even when there is no real danger.

Perhaps a similar logic is involved in the feeling of tightness. The feeling happens when we unconsciously perceive (rightly or wrongly) that there is a threatening condition in the muscles that need a movement correction.

So what is the threatening condition that a feeling of tightness is trying to warn us about? Surely it is not just the presence of tension – muscles are made to create tension and we often feel tightness in muscles even when they are almost completely relaxed.

So the tension is not a threat, but the absence of adequate rest or blood flow is a threat, which could cause metabolic stress and activate chemical nociceptors. So the problem that a feeling of tightness is trying to warn us about is not the existence of tension, but the frequency of tension or the lack of blood flow (especially to nerves, which are very bloodthirsty.)

With this in mind, I think of the feeling of tightness as a variety of pain, perhaps a pain too mild to deserve being called pain. But it is definitely bothersome. And it has a certain flavour or character that motivates an interest in changing resting posture, or moving around or stretching. Which is different from certain pains, which often make you want to keep still. Maybe we could say that pain is warning us to not move a certain area, while tightness is warning us to get moving.

How Can You Cure Muscle Tightness?

I think we can probably treat the feeling of tightness in the same way we treat pain – by changing one of the many “inputs” that cause the nervous system to perceive a threat in the body, such as nociception, thoughts, emotions, memories, etc.

Some pains are very obviously related to movement or postural habits. We can know this if someone says something like: “It hurts when I do this, and it hurts even more when I do more of this, and it hurts less when I do less of this.” In this case, changing movement or posture is likely to help because it will reduce the main driver of the pain – mechanical nociception caused by movement.

On the other hand, there are many other cases of pain, particularly chronic pain, that are more complex – the pain doesn’t correlate very much with certain movements or postures, but instead with other variables like time of day, sleep duration, emotional state, stress level, diet, general exercise, or some random unknown factors. In this event, it is unlikely that mechanical nociception caused by movement is the main driver of the pain, and more likely that peripheral or central sensitization are playing more of a role.

I think we can look at the feeling of tightness in the same way.

In most simple cases of feeling tight, the cause is obvious – we have been stuck in the same posture or movement pattern for too long, and our muscles need a rest or change of position to reduce the ischemia or metabolic stress that is causing nociception in certain areas. For example, if we spend hours in a car, or an airplane, or behind a computer, we will instinctively feel compelled to stretch and move, and this will usually alleviate any feelings of stiffness or yuckiness.

 

Of course, most clients who complain of chronic tightness have already tried and failed at this simple strategy. The feeling of stiffness remains for hours and days at a time, comes and goes as it pleases, and is less related to posture and movement.

In these cases, the driver of the discomfort may have more to do with the nervous system becoming either peripherally or centrally sensitized to the need for more blood flow in certain areas. This could happen through local inflammation, adrenosensitivity, increased sensitivity at the dorsal horn, or maybe even learned associations between certain environments (say computers) and certain sensations (e.g feeling like crap).

So how do we reduce this sensitivity?

There isn’t an easy answer to this question because if there was, it would solve the problem of chronic pain, and no one is figured out how to do that yet. But if I’m right that the feeling of tightness is a mild form of pain, then it should at least be easier to deal with.

Below is a list of several methods people often use to address a chronic feeling of tightness, along with some thoughts about each strategy from the above perspective. You’ll notice that some of the recommendations run exactly opposite to what people often do.

Stretching

We instinctively stretch muscles that have remained in a short position for a while, and this usually makes us feel immediately better.

But, as noted above, most people who suffer from chronic tightness have already tried and failed at this strategy, which suggests the issue is less about bad mechanics and more about increased sensitivity.

The problem is that many people, and indeed many therapists, will think that the failure of a few simple stretches indicates the need for a far more aggressive program.

Photo by: RachelScottYoga

This would, of course, make sense if the root of the problem was short or adhered tissues. But if the root problem is in fact increased sensitivity, then aggressive stretching might just make the problem worse. On the other hand, stretching can often have an analgesic and relaxing effect.

So is stretching a good way to cure tightness? Like with most things, I say if it feels good do it. If it doesn’t … don’t.

Soft tissue Work For Tightness

There are various soft tissue treatments (deep tissue massage, foam rolling, Graston, ART, IASTM) intended to lengthen short tissues, break adhesions, or melt fascia, etc. This is very likely impossible, as I and many others have pointed out.

But could these treatments decrease sensitivity and make someone feel less tight? For sure, by activating descending inhibition of nociception, which is a well-known effect of painful stimulation that is expected to bring health benefits.

But of course, these treatments also create nociception, which tends to increase sensitivity. It’s a fine balance that depends on the individual and many other variables. Again, if it feels good do it, but it’s an option, not a necessity, it’s only temporary, and you should keep in mind the reason for doing it.

Motor Control For Muscle Tightness

Many forms of movement therapy are essentially motor control approaches – they seek to change movement, postural and breathing habits so they are more efficient, eliminate parasitic tension, develop the skill of relaxation, etc.

 

Habits are hard to break, but this strategy is worth a shot, especially in cases where tightness seems related to certain postures or movements. Of course, where the situation is more complex, motor control shouldn’t be expected to fix the problem on its own.

Exercise And Resistance Training

People tend to associate strength training with becoming tighter. During exercise, muscle, of course, becomes very tense, and they may feel stiff the next day because of delayed onset muscle soreness. There is also the (false) idea that strength training makes muscles shorter and less flexible.

These concerns are unfounded. In fact, full range of motion strength training can increase flexibility, perhaps more than stretching. It creates local adaptations in muscle that may improve endurance and make them less likely to suffer metabolic distress. And exercise also has an analgesic effect and can lower levels of inflammation that cause nervous system sensitivity.

Here’s a personal anecdote. Back in the days when I did yoga, I had much more flexibility, but my hamstrings always felt tight. Then I quit yoga and started doing a lot of kettlebell swings. My forward bend decreased a bit, but the feeling of hamstring tightness was GONE, even though I was working the hamstrings HARD. In its place was a feeling of functional strength and capacity, which I imagine decreased any perception of threat related to lengthening my hamstrings.

Of course, if you overwork your muscles from strength training and don’t let them recover, they will get sensitive, stiff and sore. But if you work them the right amount – enough to create an adaptation and not too much to cause injury or prevent full recovery – then you will make them healthier, stronger, and yes – less stiff.

Conclusion

When you feel stiff, remember it is a feeling, and not necessarily a physical condition of shortness that needs an aggressive structural solution. Like other feelings, you feel it more when you are sensitive. And like other forms of sensitivity, it will go down if you improve your overall fitness, strength, awareness, motor control and health.

Update – August 30, 2017

This paper from Stanton, Moseley, et al. validates some of the speculations in this post. Here are some quotes from the abstract:

We propose a new hypothesis: feelings of back stiffness are a protective perceptual construct, rather than reflecting biomechanical properties of the back. . . . Over three experiments, we challenge the prevailing view by showing that feeling stiff does not relate to objective spinal measures of stiffness and objective back stiffness does not differ between those who report feeling stiff and those who do not. Rather, those who report feeling stiff exhibit self-protective responses: they significantly overestimate force applied to their spine, yet are better at detecting changes in this force than those who do not report feeling stiff. This perceptual error can be manipulated: providing auditory input in synchrony to forces applied to the spine modulates prediction accuracy in both groups, without altering actual stiffness, demonstrating that feeling stiff is a multi-sensory perceptual inference consistent with protection. Together, this presents a compelling argument against the prevailing view that feeling stiff is an isomorphic marker of the biomechanical characteristics of the back.

Articles Of The Week December 3, 2017

After the big news about Massage Envy and sexual assault cases, Irene Diamond wrote a post to start some discussion on how to deal with this. She opens the discussion around a “Professional Personal Boundary Agreement,” and whether it should be used.

Sexual Assault & Massage Therapists: What To Do To Protect Yourself – Irene Diamond

We posted something about being prepared with business cards this week and we, in turn, got some great advice about mobile marketing from Allissa Haines.

Online Marketing as an In-Person Networking Tool for Massage Therapists – Allissa Haines

Recognizing and awareness around concussions has come a long way in the last few years. However, there is lots we still don’t know and we need to continue to improve on treatment.

Everything We Know About Concussions Is Wrong – Quartz Media

Just like so many other things in our profession, there are many things that have myths around them. Pregnancy and many things about pregnancy have lots of myths surrounding it. This is a great article to help dispel some of them.

What To Expect When You’re Expecting – American Physical Therapy Association

A great anatomy review of peripheral nerve roots, along with an explanation of what they do, with this post from Diane Jacobs.

Anatomy Of A Peripheral Nerve Root – Diane Jacobs

Client-Centred, Or All About You?

*This post was originally posted on Laura’s blog on June 28, 2016

This morning I saw a FB post from a practitioner mentioning all the things he throws into a massage…Reiki, toning, spiritual healing, and Qi Gong. When I questioned him, he assured me that his clients know before getting on his table what they’re in for. This is the only way of working with integrity. 

My questions about those things, and anything else other than massage that you include in sessions:

1. Did the client ask for it?

I was attending classes in energy work for five years before attending massage school almost 17 years ago. I was taught that you should never impose it on clients who have not asked for it, as many may have religious objections to it or just not believe in it–or just be intent on getting the full hour of massage that they have paid for without other things they aren’t expecting being thrown in. I always adhered to that policy in the interest of being client-centred.

2. Was the client informed before getting on the table that this is the way you conduct all your sessions, and given the opportunity to refuse in the event they just want a massage and nothing more?

If a client books a massage, they are expecting a massage. Particularly in the case of a client who has never had a massage, they are not expecting you to delve into their private spiritual beliefs or perform rituals that they know nothing about.  If you are an “integrative” practitioner and you throw in other things during your session, that needs to be made clear at the very first contact.

It is the same principle as putting nut oil on a client without asking them if they have a nut allergy, or putting essential oils on someone who may have allergies or just object to the fragrance. Just because you love to use peppermint oil during a massage doesn’t mean the client is going to enjoy it.

People have the idea that I am against energy work. I am not against it. I believe anytime you place your hands on people in a compassionate, non-sexual, non-threatening, non-judgmental way, with the intention of soothing their pain, relieving their stress, easing their passing, or whatever, that’s a good thing, and you can do the work without needing some supernatural  narrative that violates the physical laws of the universe to go along with it. A good explanation from Keith Eric Grant, who might be the only physicist in the US who is also a massage therapist of many years, can be found here.

I taught Reiki for ten years myself. One day it struck me that my drawing a few symbols in the air and blowing a puff of my breath on someone is never going to turn anyone into a healer, and I tore up my master certificate. I came to the conclusion that I can lay my hands on someone without needing a story to go along with it, outside of “I just want to comfort you.”

3. Do you wait until they are on the table to spring your plans for the session on them when they are already relaxed and possibly in an altered state of consciousness?

There is an inherent power differential in the therapeutic relationship that is in our favour, and that clients look at us as the authority figure who knows what they’re doing, and who is supposed to have their best interests at heart.

4. Are you client-centred, or is it all about you?

If a client has booked a relaxation massage, and you start digging in because you have decided they need a deep tissue massage, it’s all about you.

I gained numerous clients over the years from massage therapists who thought it was all about them. I’ve heard many comments such as “She was just sitting there with her hands on me not doing anything. I thought she went to sleep.” And “He walked around the table banging a little gong and said he was clearing my negative energy.” And “I kept asking him to lighten up because he was hurting me, but he said he couldn’t because this is what I need.” And “I just can’t stand strong fragrances of any kind. Before I knew what was happening, she had doused me with some kind of oil and I thought I was going to choke.”

A therapist who is client-centred is a successful therapist. A therapist who is not client-centred is going to crash and burn a year or two in and wonder why they just couldn’t make a living doing massage. Being client-centred isn’t optional; it’s our obligation.

Articles Of The Week November 26, 2017

“Your Body Is (probably) Not As Broken As You Think” – Heather Thuesen

The way we talk to our patients is really important, like REALLY important. Heather does a great job of talking about what massage therapy does and does not do. And more importantly, talks about how to talk and educate your patients about pain.

‘It’s Like Chalk On A Blackboard’ My Experiences Researching Patellofemoral Crepitus  – Claire Robertson

This is a great article as it gives lots of research and background on Patellofemoral Crepitus but also shows how a patients beliefs are just as important to acknowledge and treat as the condition itself.

Why I Have Gymnasts Track Sleep Fatigue, And Soreness Every Day – Dave Tilley

If you work with athletes, they really like to track things like progress, success, gains, and almost everything in between. This article is from coaches perspective on why they have their athletes track certain things, so the coaches can alter their training program accordingly.

Shifting Away Nociception And Mesodermalism And Towards “Yesiception,” neurocentrism, and pain science – Alice Sanvito

I’ll admit, this one was written a while ago, but I just came across it this week. It’s a bit of an introduction to pain science if you’re new to it. However, what I love about it is how Alice shows, you don’t have to really change what you’re already doing in practice, you just need to change your description. It’s well worth the read. 

How Important Is Muscular Symmetry For Strength Sports – Greg Nuckols

Our bodies aren’t symmetrical, so do we lift things symmetrically? Is it even important? Well, it probably is for a physique competition, but not so much when it comes to activities like lifting. There may be instances where it could help with injury prediction, but overall it’s not that big of a deal. But if you want to be more symmetrical, or your patient does, the article also gives some advice on that.