Posture: the scapegoat of pain

There is currently an ongoing debate of posture and it’s relationship to pain. Posture causing pain is actually mostly theoretical and situational, while posture not being correlated to pain has been shown in studies, yet we still debate this and many misinform people regarding the topic. A common info-graphic is the one shown below. It tried to show that there in increased force or load from having a forward head. The image above tends to be interpreted as a negative thing, but isn’t one way of getting stronger by increasing load? So wouldn’t the person with forward head posture have strong neck muscles holding that head up all day? Want to get stronger legs; then squat more weight, want stronger arms; curl more weight. Obviously this is a bit different in terms of external load vs internal load. I think most people take these things as absolutes when they are not.

At the same time I will say that posture can potentially play a role in neck pain, but definitely not the sole cause and not to the extent that one may think. Much like driving a car can play a role in car accidents. According to the U.S. Department of Transportation, more than 25% of all drivers will be involved in a car accident in a five year period. You may wonder what that has to do with anything, I’ll come back to it. In terms of the relation of neck pain and posture, a recent study (1) that looked at students between 18 and 21 were asked to fill out a questionnaire. The results were that 75% of the students reported using their cell phones for more than 4 hours a day. Over 80% of the students reported their posture as being “inappropriate” while using the device. If posture was directly related to pain then there should be a pretty high number of students with neck pain right? Well turns out that only 36% of the students had neck pain. If only 36% of those 80% with bad posture had pain and we try to assume that posture leads to pain from that, then with 25% of drivers getting into accidents can we assume that driving causes accidents? Do you have people going around saying “don’t drive, you’ll get hurt”? There's other factors for driving accidents such as "don't drink and drive" just like there are for neck pain "don't sit there all day in one position without any activity". There are many more confounding factors in both cases. Now I know it’s not the best comparison since you can’t be a driver in an accident without a car, but you can also have “good” posture and still get neck pain.

At the same time I think posture can play a small role, smaller than other possible contributing factors. One factor often overlooked is general activity levels. There is evidence that lower activity levels lead to a lower pain threshold, meaning it takes less stimulus to get the output of pain (2,3). With that alone one can now say posture can be irrelevant if you’re active and more relevant if you are sedentary. I won’t stop there though, I’ll dive a bit further. Imagine holding a bicep curl half way up all day, your likely to do a number on your biceps, if you broke that up into only chunks of the day, it would be less likely to be an issue. Same can be applied to the neck, if the muscles of the neck get strained from a constant position then would moving a bit more throughout the day and breaking up the time in any given position mitigate that as well? On top of that if your neck muscles got stronger over time then they would be able to tolerate more time with your head forward. I am sure we all know someone who has this posture yet has no pain. Of course we can’t forget how the sheer perception that certain postures are inherently bad may affect ones perception of pain.

When someone has neck pain it’s easy to point the blame on posture, and in turn on technology, but before smart phone people were tilting their heads forward to read books and newspapers, they were also more active overall. Look at the image of the athletes above, at rest they seem to have what some would call bad posture. If those postures were really that bad then wouldn’t people around them tell them to avoid it at all costs, after all their health and performance is worth millions and even billions of dollars. The key with them is that with their sport related activities they tend to be on the move, meaning relatively active but also constantly changing their postures.

So let’s give a bit of a summary of my take on posture and specifically related to neck pain. Pain is not cut and dry. There are many factors that influence pain, to say that posture in any way causes pain would be to marginalize the other and potentially more important factors such as activity levels. There is no such thing as bad posture, because even those with “good” posture can still get pain. You could even make a strong argument that spending most of your day rotating between 3-4 “bad” postures is actually more ideal than spending your entire day in an “ideal” posture.

So what you want to do is change positions throughout the day as well as be more generally active, that way there should be no problems whatsoever with you having your head forward as you read this article about posture.

Thanks for reading, Vitas

References:

1. Damasco GM, Ferreira AS, et al. “Text neck and neck pain in 18-21 year-old young adults.”

2. Hennings A, Schwartz MJ, Riemer S, et al. “The influence of physical activity on patients with depression an somatoform symptoms” Clin J Pain. Nov-Dec. 2012.

3. Tarr B, Launey J, Cohen E, et al. “Synchrony and exertion during dance independently raises pain threshold and encourage social bonding” October 2015.