[ viewpoint ]

DIANE SLATER, MSc, PG Cert, BSc (Hons)1 • VASILEIOS KORAKAKIS, PhD, MSc, BSc1
PETER O’SULLIVAN, PhD, Grad Dip Manip Ther, Dip Physio2,3 • DAVID NOLAN, MSc Physiotherapy4
KIERAN O’SULLIVAN, PhD, M Manip Ther, B Physio1,5,6

“Sit Up Straight”:
Time to Re-evaluate
J Orthop Sports Phys Ther 2019;49(8):562-564. doi:10.2519/jospt.2019.0610

P
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osture is a frequent topic of discussion for patients, clinicians, suggest that correct posture prevents or
the media, and society. A common belief is that spinal pain is reduces pain and disability. People with
caused by sitting, standing, or bending “incorrectly.” Despite the low back pain bend their spine less and
show more trunk muscle activity when
absence of strong evidence to support these common beliefs,
forward bending and lifting. The notion
a large posture industry has flourished, with many interventions and that people with low back pain must be
products claiming to “correct” posture and prevent pain. Unfortunately, careful and “protect” their spine is further
many health care professionals provide advice in line with this non– challenged by the association of higher
evidence-based perspective. In this View- beliefs likely reflect the fact that sitting, levels of fear and lower self-efficacy with
point, we reflect on common beliefs re- standing, and bending are often provoca- a guarded way of moving.2
garding posture and spinal health and tive for complaints such as low back pain. The non–evidence-based perspective
why they are so widely held, and consider Awkward postures and heavy lifting may that pain can be prevented by avoiding
how clinicians can positively influence precipitate episodes of acute low back incorrect posture, such as slouching, is
these beliefs. pain, and some links between lifting and reinforced by fear-inducing messages in
J Orthop Sports Phys Ther 2019.49:562-564.

injury have been reported. Despite wide- the mainstream media. People might be-
Beliefs About Posture spread beliefs about correct posture, there come concerned about their spinal health
Health care professionals and the com- is no strong evidence that avoiding incor- when they are exposed to articles about
munity typically agree that avoiding spinal rect posture prevents low back pain, or potentially damaging postures and ad-
flexion is the safest way to sit5,9 and bend.8 that any single spinal curvature is strongly vertisements for posture-correction aids.
Patients and pain-free members of the associated with pain.6 Unhelpful posture ideals are also rein-
community are commonly advised to sit Protecting the spine is also advocated forced by long-standing stereotypes that
upright and undertake bending and lift- by the fitness industry. Common advice suggest posture reflects a person’s sex,
ing tasks in a “natural” lordotic posture. is that the “core” muscles of the trunk dignity, respectability, attractiveness, and
Manual handling guidelines in the United must be consciously activated to main- morality.3
States and the United Kingdom advocate tain a “correct” posture and protect the
a straight back or a slight bend of the back spine. Advice about “perfect form” given Assessing the Posture of People With Pain
during lifting tasks. A slightly lordotic in relation to weight-training is often Observing the posture of a person pre-
posture is also commonly identified as the applied away from the lifting platform. senting with musculoskeletal pain has a
ideal standing position.5 The assumption While there is additional muscular effort role. It may help patients to feel they are
is that maintaining these postures might required for correct posture when sit- being taken seriously and allow the cli-
protect spinal structures, and posture ting and lifting, there is no evidence to nician to identify rare cases of clinically

1
Sports Spine Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar. 2School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia. 3Body Logic
Physiotherapy, Shenton Park, Australia. 4PhysioWorks, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom. 5School of Allied Health, University of Limerick,
Limerick, Ireland. 6Health Research Institute, University of Limerick, Limerick, Ireland. Diane Slater and Professors O’Sullivan and O’Sullivan provide professional development workshops
on low back pain, which incorporate/discuss the role of posture in low back pain. The other authors certify that they have no affiliations with or financial involvement in any organization
or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Diane Slater, Sports Spine Centre, Aspetar Orthopaedic and
Sports Medicine Hospital, PO Box 29222, Doha, Qatar. E-mail: [email protected] t Copyright ©2019 Journal of Orthopaedic & Sports Physical Therapy®

562 | august 2019 | volume 49 | number 8 | journal of orthopaedic & sports physical therapy

 relevant deformity such as a significant, 30 minutes in one position is dangerous useful to explore different postures. The
deteriorating scoliosis. Importantly, the or should always be avoided. clinician might consider how to expose
clinician may observe overly protective “It’s Caused by Your Swayback Pos- people to postures and ways of moving
postures, levels of muscle tension, appre- ture”  There is some resistance within that they have avoided, and how to en-
hension, vigilance, distress, mood, and health care to shift away from the biomed- courage change in habits that may be
body image that can provide insights ical model of pain. Consequently, pain is provocative. Alterations in posture or
into behavioral responses and how people often ascribed to relatively “normal” varia- movements that feel good in the acute
make sense of their pain experience. We tions and asymmetries, despite the lack of stage may not be needed long term.
strongly encourage building a relation- strong evidence. We urge clinicians to be Some people who find upright pos-
ship with patients to explore why they cautious in their explanations to avoid fur- tures provocative may be required to
adopt certain postures. Although there is ther worry about posture “flaws.” adopt such a posture for their sport/role
evidence that people with low back pain (eg, ballet dancers, military personnel). It
may find certain postures provocative,1 it Clinical Recommendations: Help People is possible for people to be upright and be
cannot be concluded that the postures are to Sit, Stand, and Move More Easily more relaxed. If clinicians help people to
the cause of pain. Helping people to adopt more relaxed experience an upright, relaxed posture, it
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postures, while reassuring them that may be beneficial—even symptom modi-

Assessing the Posture of these postures are safe, can provide fying! Although the posture may be re-
People Without Pain symptom relief.4,7,10,12 Comfortable pos- quired for the sport/role, it may not be
There is no evidence to support posture tures vary between individuals, so it is required for spinal health and, as such,
or movement screening for primary pre-
vention of pain in the workplace. People
1. There is no single “correct” posture. Despite common
come in different shapes and sizes, with posture beliefs, there is no strong evidence that one
natural variation in spinal curvatures. optimal posture exists or that avoiding “incorrect”
Preferential lifting style and posture postures will prevent back pain.
adaptability are influenced by spinal 2. Differences in postures are a fact of life. There are natural
curvatures.11 The mandatory manual variations in spinal curvatures, and there is no single spinal
handling training and ergonomic assess- curvature strongly associated with pain. Pain should not be
attributed to relatively “normal” variations.
ments in offices that pain-free people are
often subjected to may perpetuate a mis- 3. Posture reflects beliefs and mood. Posture can offer insights
into a person’s emotions, thoughts, and body image. Some
conception that common daily tasks and
J Orthop Sports Phys Ther 2019.49:562-564.

postures are adopted as a protective strategy and may reflect

working environments are dangerous. concerns regarding body vulnerability. Understanding reasons
behind preferred postures can be useful.
“Mind Your Back”: Mind Your Language! 4. It is safe to adopt more comfortable postures. Comfortable
The iatrogenic nature of low back pain is postures vary between individuals. Exploring different postures,
a reminder of the clinician’s responsibil- including those frequently avoided, and changing habitual
ity to be mindful of the language we use. postures may provide symptom relief.
Advice given by clinicians can lead to fear 5. The spine is robust and can be trusted. The spine is a robust,
and encourage hypervigilance. Here are adaptable structure capable of safely moving and loading in a
some examples. variety of postures. Common warnings to protect the spine are
not necessary and can lead to fear.
“Sit Up Straight”  In the absence of any
good evidence that one posture exists 6. Sitting is not dangerous. Sitting down for more than 30
minutes in one position is not dangerous, nor should it
to prevent pain, asking patients to work
always be avoided. However, moving and changing position
hard to achieve correct posture may set can be helpful, and being physically active is important for
them up for a sense of failure and create your health.
more anxiety when their pain persists.
7. One size does not fit all. Postural and movement screening
“Sitting Is Bad for You” Encouraging does not prevent pain in the workplace. Preferred lifting styles
people to move and change position can are influenced by the naturally varying spinal curvatures, and
be helpful. Sedentary lifestyles are a risk advice to adopt a specific posture or to brace the core is not
evidence based.
factor for low back pain, among many
Acknowledgment: The authors would like to thank Kevin Wernli @KWernliPhysio for his assistance in developing the
other health conditions. Nevertheless, it illustrations for the figure.
is important for clinicians not to perpetu-
FIGURE. Key points to change the posture narrative.
ate worry that sitting down for more than

journal of orthopaedic & sports physical therapy | volume 49 | number 8 | august 2019 | 563

 [ viewpoint ]
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@
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564 | august 2019 | volume 49 | number 8 | journal of orthopaedic & sports physical therapy