I was recently reading a 2012 article from the Forward Thinking PT titled, "Drop the plumb line...static posture assessments were so last decade." In the post, the author discusses how he does not use static postural assessments because the abnormalities that clinicians find are not truly abnormalities, but rather differences. Additionally, he states that visual examination and assessment are insufficient to make clinical decisions. The author sites several research articles that support the belief that habitual patterns are not related to musculosketal pathology. The most profound article (in my opinion) that he cites recommends that physical therapists should not perform abdominal muscle strengthening in individuals with chronic low back pain based solely on relaxed standing posture.
Reading the Forward Thinking PT article may seem daunting for many physical therapists. Almost every therapist I encounter assesses static posture. Many follow the notion that good posture will minimize microtrauma across the joints and decrease the incidence of musculoskeletal injury. In theory, an individual's static posture will alter muscle length and tension, which will alter their movement patterns. Shirley Sahrmann founded much of her Movement Impairments Syndromes off this belief. For example, an individual with increased lumbar lordosis likely have weak abdominal muscles and will need motor control exercises to control the lumbar spine during functional movements. If that patient chronically rests in lumbar lordosis, one would assume they are at an increased risk of injury. Changing the static posture would be a logical starting point to affecting their pain.
My Thoughts on the Subject
Based on the cited research, the Forward Thinking PT article is correct. A pure static assessment has not shown to be a reliable measure for choosing your treatment options. Fortunately, we rarely treat based off static movement assessment alone. The articles provided do not address functional movements. I agree with the author that clinical decisions should not be based on a static snapshot. Personally, I am more concerned with how the patient moves. With that said, I often use static postural assessment as a baseline to guide which functional tasks I want the patient to perform. For example, if a patient has a forward head, rounded shoulder posture, I know I want to see their overhead flexion. The forward head presentation cues me to assess the mobility of the CTJ, the strength of the DNF, and strength of the low trap. These impairments are likely the biomechanical contributors to the pain. Addressing the biomechanical contributors is often successful, BUT not always. As the Forward Thinking PT points out, we also need to address the patient's perception of pain. We need to change the patient's perceived threat of pain and reprogram the brain to decrease the threat of injury. This can be addressed by performing repeated motions, manual therapy, graded exercises, and neuroscience education. Along with these interventions educating on proper posture is essential, especially during the acute phases.
In conclusion, we need to combine the biomechanical approach with the biopsychosocial and pain matrix approaches. Normalizing postural mechanics both statically and dynamically will decrease the stress placed across the musculoskeletal system and prevent re injury from occurring. Additionally, we must change how the brain perceives pain. If we do not change the perception of pain, we will not be successful.
Thank you Forward Thinking PT for the thought provoking article! I enjoy reading all your content.
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