The Quandary of Spinal Alignment and Posture
Updated: Oct 9, 2019
Reading Time: 10 minutes.
Spinal alignment and posture is something that chiropractors have been long obsessed with treating and is often attributed as the cause of spinal pain and something that needs to be fixed to eliminate or prevent pain. Is this paradigm of treatment still relevant? Contemporary thinking has changed in light of all the information we have now, and in this article I would like to give you some insight into the current state of affairs as it relates to assessing and treating spinal alignment and posture.
Why Worry About Posture/Alignment at All?
Good posture is supposed to help us expend less energy as our mass is centered and stacked in such a way that requires little muscular effort to fight the force of gravity. One author cites that standing only utilizes about 7% more energy than laying on your back. The assumption is that bad posture displaces your center of mass and requires more energy by your muscles to keep you upright. Also, good posture has cultural and societal importance. Who hasn't been told to "sit up straight or don't slouch" as a child?
But It's Not a Clear Cut Problem
Traditionally, this problem has been dealt with in chiropractic by taking x-rays accompanied by measurements and comparisons to "ideal" ones, followed with a treatment plan of adjustments in attempt to push our vertebrae into place. The reason is because poor alignment of the spine has always been thought to be the cause of spinal pain due to poor joint articulation or increased joint pressure. The closer we can be to ideal, the better we should feel. However, studies on different treatment methods (chiropractic & non-chiropractic) over the years have produced improvements in neck and back pain (see the Knowledge Center) without even evaluating spinal alignment as a parameter. Also, many studies have demonstrated a poor correlation between alignment and symptoms as they find people with poor postures with and without pain. But contrary to former, there have also been studies that demonstrate decreased quality of life and pain with poor posture. In light of this conflicting information brought forth by researchers, the best we can say is that alignment and posture may be a significant contributor to your pain, but it might not be. This is why it's important to look at your history and environment to put the issue in context. Lastly, posture isn't purely a biomechanical issue anymore either. Research has been put forth that suggests there is a psychological component as well.
Do We Need X-rays?
As I alluded above, there has been much research that demonstrated no significant correlation between a patient's radiograph and their symptoms. Current guidelines also caution against the routine use of x-rays without good clinical reason to reduce radiation exposure to patients.
Despite that fact about x-rays, it is interesting to note that some of our medical colleagues are particularly interested in analyzing spinal alignment and posture on x-ray as it is not possible to do on MRI (no radiation) due to positioning. In planning for corrective surgery to reduce pain, back surgeons will sometimes normalize spinal curves to "ideal" measurements when they have to operate on patients. They have gone so far to create standards of alignment and balance on x-rays to help align the pelvis and entire spine in an attempt to reduce pain and improve quality of life as it has been reported that patients with better posture post-surgery score higher on quality of life measurements. But imaging also serves another purpose in surgical planning as the changes they make may have pronounced effects. If they remove part of the spine, they may introduce additional degrees of movement that weren't previously present. This could potentially accelerate wear and tear of joints. If they install hardware to stabilize an area, that could possibly limit motion and limit gross mobility or cause hypermobility in an adjacent area to compensate. When looking at the utility of x-rays from this perspective, it seems to suggest that they can be beneficial to look at the entire spine.
While this issue has valid arguments on both sides, it usually comes down to the preference of the individual practitioner. Professionally, I agree with current standards of avoiding excessive radiation exposure as it is known to be a cancer risk. In the words of one researcher that has been echoed in many research studies throughout the years, "Treat the patient, not the image." Our brethren therapists (Physical, Physio, Massage, etc.) have also been treating posture and pain along side with us for years, often without x-rays either. But for all this effort by practitioners to create good spinal alignment and posture, I think there remains a very important question that must be asked.
How Often Do We Even Spend Time in "Ideal" Posture?
As stated by some studies, it is not common to come across individuals with ideal posture in practice. But even if we have it, or trained people to have it, how much time do we even spend in it? To date, there have been very few studies that have attempted to answer this question. In one that studied the alignment of the low back, researchers placed measurement devices on the low backs of 208 volunteers with no low back pain and tracked their low back curvature for 24 hours. They found that the average curvature of the low back was 8 degrees in a 24 hour period compared to the standard 33 degrees (about same as what is considered ideal on x-ray) measured while standing. That meant the subjects were doing more activities (such as sitting) that involved forward bending of the low back for the average to be so far off the standing standard. Due to the more sedentary nature of modern life, the researchers postulated that it may be beneficial for back surgeons to take x-rays of patients in seated position to get a better sense of their more natural state.
In another small study, subjects were asked to replicate and sustain various sitting postures with different curves in the low back based on pictures and therapist feedback. The subjects found that it was harder for subjects to produce postures that required a curve in the lower back as seen in standing. The researchers reference other studies that suggest more slouched postures require less energy to maintain, but shifts support to passive structures such as ligaments and tendons which carries a potential injury risk.
This tells us a couple things. First, static snapshots of our spine and posture aren't enough to give us the whole picture about our lives. Second, it can be hard or difficult to sustain postures, as the body gets tired and seeks to conserve energy. This is confirmed in real life practice as clients often tell me things like: "I try to sit with good posture, but after a while I forget", or "I recently got a standing desk, but I start to get tired and lean on it after a while".
Taking all this information, I believe the body is best in having a balanced variety of movement and positions throughout the day. To live is to move and we should be able to go through many ranges without too much thought. I believe that is our natural state of being. I often joke with patients, that if it was strictly about posture and alignment, I would place them in a body cast or brace and my job would be done, but this simply would not solve all their problems and would likely create other ones as you can imagine.
Does This Mean That Posture and Alignment is Never Important?
Not at all. If we are to aim for what has been "ideal" posture, then it is most likely to be expressed in standing and walking, which the time spent doing will vary individual to individual. But even in those movement patterns, the spine and several joints aren't completely static the whole time. This is where we need to balance form and function as conservative practitioners because people have so much potential for movement. So many things could affect a person's alignment and posture (repetitive tasks, emotional state, energy levels, adaptations to the environment). This is why I place more emphasis in mobility and motor control as a practitioner. Without mobility, you may not even be able to obtain whatever posture you seek to obtain, and without motor control, you may not be able to sustain or support that posture. In practicing this way, the issue becomes a matter of helping individual adopt the right posture for the task at hand.
If this post got you thinking, "Maybe I can benefit from better posture," come by and see one of the best-reviewed chiropractors in Kirkland, Dr. Frank Wen.
Chaitow L. Is a postural-structural-biomechanical model, within manual therapies, viable?: A JBMT debate. Journal Of Bodywork & Movement Therapies [serial online]. April 2011;15(2):130-152. Available from: CINAHL Complete, Ipswich, MA. Accessed December 9, 2017.
Claus A, Hides J, Moseley G, Hodges P. Original Article: Is ‘ideal’ sitting posture real?: Measurement of spinal curves in four sitting postures. Manual Therapy [serial online]. January 1, 2009;14:404-408. Available from: ScienceDirect, Ipswich, MA. Accessed December 9, 2017.
Diebo B, Varghese J, Lafage R, Schwab F, Lafage V. Sagittal alignment of the spine: What do you need to know?. Clinical Neurology And Neurosurgery [serial online]. December 1, 2015;139:295-301. Available from: ScienceDirect, Ipswich, MA. Accessed December 9, 2017.
Dreischarf M, Pries E, Bashkuev M, Putzier M, Schmidt H. Differences between clinical “snap-shot” and “real-life” assessments of lumbar spine alignment and motion – What is the “real” lumbar lordosis of a human being?. Journal Of Biomechanics [serial online]. March 21, 2016;49:638-644. Available from: ScienceDirect, Ipswich, MA. Accessed December 9, 2017.
Galbusera F, Lovi A, Bassani T, Brayda-Bruno M. MR Imaging and Radiographic Imaging of Degenerative Spine Disorders and Spine Alignment. Magnetic Resonance Imaging Clinics Of North America [serial online]. August 1, 2016;24(Update on Spine Imaging):515-522. Available from: ScienceDirect, Ipswich, MA. Accessed December 9, 2017.
Klineberg E, Schwab F, Smith J, Gupta M, Lafage V, Bess S. Sagittal Spinal Pelvic Alignment. Neurosurgery Clinics Of North America [serial online]. April 1, 2013;24(Spinal Deformity Surgery):157-162. Available from: ScienceDirect, Ipswich, MA.
Accessed December 9, 2017.
Laura L, Luciano L, Francesco C. Loss of cervical lordosis: What is the prognosis?. Journal Of Craniovertebral Junction And Spine, Vol 8, Iss 1, Pp 9-14 (2017) [serial online]. 2017;(1):9. Available from: Directory of Open Access Journals, Ipswich, MA. Accessed December 9, 2017.
Lunghi C, Tozzi P, Fusco G. The biomechanical model in manual therapy: Is there an ongoing crisis or just the need to revise the underlying concept and application?. Journal Of Bodywork And Movement Therapies [serial online]. October 2016;20(4):784-799. Available from: MEDLINE Complete, Ipswich, MA. Accessed December 9, 2017.
Masi A, Hannon J. Physiology Review: Human resting muscle tone (HRMT): Narrative introduction and modern concepts. Journal Of Bodywork & Movement Therapies [serial online]. January 1, 2008;12(Special Section: Series of Fascia Congress Abstracts - Part 2 (pp. 320-396):320-332. Available from: ScienceDirect, Ipswich, MA. Accessed December 9, 2017.
Radwan A, Fess P, Torii A, et al. Effect of different mattress designs on promoting sleep quality, pain reduction, and spinal alignment in adults with or without back pain; systematic review of controlled trials. Sleep Health [serial online]. December 1, 2015;1:257-267. Available from: ScienceDirect, Ipswich, MA. Accessed November 7, 2017.