Do I Have to Stand Up Straight?

By Daniel Wonnocott

Postural assessment is one of the first assessment skills most therapists are taught and correcting posture is often touted as a solution to a client’s aches and pains.

During the initial intake, many massage therapists undertake a postural assessment. The therapist runs an eye over every element of the client’s posture, looking for anything that doesn’t fit some ill-defined “good” posture. But what does it actually tell us about the cause of our clients’ presentation? And is focusing on correcting posture the best we can offer clients?

What if:

• The client has always had this posture but only had their presenting complaint for a few days?
• There is a structural change that is outside of their control?
• The client is comfortable in this posture?
• The posture is protective and not a true representation of their “normal” posture?

What are we looking at anyway?

When someone is in pain, it seems logical for them to avoid positions that aggravate their symptoms and adopt positions that relieve symptoms. A tilt here and a twist there may not be visually symmetrical and may require asymmetrical muscle use to hold, but it might be useful in the interim for the client to feel safe until things settle down.

Think about a strained muscle or sprained ligament. Would it affect the way you move and how you hold your body? Or imagine fracturing your foot and trying to maintain even weight through both feet.

In this instance, the “poor” posture our client presents with is not the cause of the mechanical provocation. Rather, it provides them with relief. Focusing on changing posture towards an “ideal posture” in this situation may lead to more sensitivity. The focus needs to be on calming the nervous system and restoring normal function to the affected area.

In other instances, nerves may become sensitive to tension and might be offered some protection by the muscles changing the joint positions to unload it. Think of an elevated and protracted shoulder with a slightly bent elbow: could this client be protecting the median nerve from excess tension? Or the client who always has really tight hamstrings and calves: are they trying to protect an unhappy sciatic nerve from being overstretched? Suddenly working out that tight muscle and stretching (tensioning) it regularly until “proper” alignment is achieved seems pretty redundant. Shifting focus towards reducing the sensitivity and improving the tolerance to stretch on the nerve is key to helping your client with this presentation.

What about the client who comes in stressed, anxious or depressed? Is picking apart their posture and highlighting any supposed faults going to help them unwind and feel better?

Simply looking at someone’s posture cannot give us this insight. A good subjective and objective assessment will likely help you come to a working diagnosis, but the postural assessment offers no real value in this scenario.

I would argue that we could skip the postural assessment and still gather all the relevant information by listening to our clients, asking good questions, using our clinical reasoning skills and orthopaedic testing. A good assessment will usually help explain the postures we see, but the posture itself doesn’t tell us why it has been adopted.

Should postural correction be a treatment goal?

If a client presents with less than ideal posture and no underlying issues, is it still worth working towards improving their posture?

This is a fair question. However, I argue that simply looking to improve postural symmetry and alignment falls short of helping a client get the best out of their body.

Given that posture is but a snapshot in time, striving to be proficient in standing still doesn’t take into consideration the plethora of potential positions and functions a client may need to undertake in their daily lives. And the only person who can help us define a suitable treatment goal is our client.

• What movements do they need to perform regularly?
• Can they access the required ranges of motion?
• Are they proficient in these movement patterns?
• What types of loads are involved?
• Do they possess the strength to control loads effectively?
• What is their level of conditioning in relation to the things they would like to be doing?
• Is there an adequate reprieve from the ongoing demands faced for healthy adaptation to occur?

The challenge isn’t in identifying postural faults but rather is helping our clients understand where they are in the present and how to prepare for the future. Those requirements will likely change as often as their posture does.

Focusing on building up qualities that help make someone more robust and resilient will better serve them to fluidly transition between all the postural possibilities they encounter in their day-to-day lives. Focusing on enhancing someone’s ability to tick off a static postural checklist we learnt in college might make treatment planning easier but it doesn’t take into consideration the complexities of an individual’s situation and what qualities, if any, require attention.

Is Postural Assessment Still A Thing?

How often has a client walked into your clinic and told you that they already know they need to “work on their posture”? How many clients walk out of an appointment with essentially the same sentiment – their “posture is the cause of their problems”?

What do you do when a client has “good” posture but still has pain?

What are the implications of how we discuss and integrate posture into our treatment?

If postural assessment doesn’t provide us with insight into the cause of a client’s presentation and it doesn’t help us determine what type of intervention is required to help them reach their goals, one might question the need for assessing and correcting posture at all.

As therapists, we hold a position of power and influence. Our words and explanations hold weight. The information and advice we give needs to be relevant, up to date and based on sound reasoning and common sense.

There is still no sound and agreed upon definition of what “good” or “bad” posture is, yet it is often touted as being a main factor for a client’s pain without any question or review of current evidence.

Pain is a very complex and multi-factorial experience. Instilling unvalidated explanations into our clients can have a lasting effect. How a client views their body, and the beliefs they hold around it, can play a role in their behaviours, actions and emotions. Our interactions have the potential to shape a person beyond the table. Telling a client they have “bad” posture fails to provide any real insight or path forward, and offers no benefit. It might also leave the client feeling ashamed, or fearful and untrusting of their body, or result in them investing time and money on treatments aimed at correcting posture under the false premise that it is the cause of their pain. Adding to a client’s stress, fear, concern and financial burden is more likely to have a negative impact on their experience of pain.

Where to From Here?

It is the responsibility of all therapists who use posture as an explanation for pain to change the narrative. The good/bad posture explanation is out. Listening to our clients and designing treatment plans that will make a positive impact upon them is in.

I wish I had a nice simple method or system to gift you (or charge $$$ for a weekend course to teach you the one technique that you need to know if you’re serious about helping your clients). However, people are complex and so is the human body. The good news is that both are incredibly robust, adaptable and respond well when given the chance in the right environment.

Maybe, just maybe, if we offered some support and encouragement, and helped our clients thrive in their environment, good things will happen.

Further Reading

Does Posture Correction Matter by Paul Ingraham

What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? David Nolan et al, Musculoskeletal Science and Practice Volume 33, February 2018, Pages 35-40

Drop the plumb line … static posture assessments were so last decade by Joseph Brence

Upright and Uptight by Tom Jesson

About the Author

Daniel Wonnocott is a family man, therapist and educator. Dan learned the hard way that you should never eat anything bigger than your own head.