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

One of the first assessments I learned in Physical Therapy school was “the plumb line assessment”.  This test helps us determine abnormalities from a “normal” static posture. These abnormalities supposedly lead to pain.  There is even a website devoted to reviewing abnormalities from this and what it means.  But what does static posture really tell us and how does it relate to our patients symptoms?

From my understanding of pain and modern neurophysiology, I argue that we can drop the plum line (and static posture assessments) professionally and can continue to have clinical success.   I suspect we can stop assessing iliac crest height, head position and lumbar lordotic curves and be just ok.  Why? Because it appears that these abnormalities are truly not abnormalities, but differences, which have little relationship with pain.  In addition, our reliability for visual examination and assessment just stinks.

But you don’t have to take my word for it… what does the literature tell us?

A 2003 article assessed our ability to detect cervical and lumbar lordosis.  It was appropriately titled, “Reliability of the visual assessment of cervical and lumbar lordosis: how good are we?”.  The study was a blinded test-retest design to determine intra and interrater reliability values.  The results?  Our intrarater reliability is fair and our interrater reliability in determining “lordosis” from a pure visual assessment is POOR.

In 2010, a systematic review was published which assessed the relationship between awkward occupational postures and low back pain.  This included a wide-range of “high risk” professions including scaffolders, nurses, podiatrists, firefighters, etc. The authors concluded there is strong evidence to support there is no relationship between prolonged static posturing and the development of low back pain.   It would be expected that individuals with these professions would have higher incidences of low back pain but statistically , they did not.

Another article published in 2007 in Manual Therapy assessed the relationship between sustained static posturing and postural neck pain.  Similar to the systematic review, the authors found that neck pain was not associated with the individuals habitual postures or kinesthetic sensibility.   The study came to this conclusion after assessing the habitual sitting posture, perception of good posture and postural repositioning error in symptomatic and asymptomatic individuals.

The last article which I want to challenged the concept of lumbopelvic imbalances and pain.  Many Physical Therapists believe that excessive lumbar lordosis is due to weak abdominal muscles in combination with shortened lumbar extensor and hip flexors muscles, which in turn leads to pain. This positional fault leads to an anterior pelvic tilt which should be addressed through abdominal stabilization (often utilizing  the infamous posterior pelvic tilt).   The article assessed 30 men and women who had chronic low back pain (CLBP).  It assessed the location of pelvic inclination and magnitude of lordosis and found that in individuals with CLBP, there was no more standing lumbar lordosis or pelvic inclination than their counterparts with healthy backs.  In patients with CLBP, the magnitude of the lumbar lordosis and pelvic inclination in standing was not associated with the force production of the abdominal muscles. The authors go as far as concluding,

“Abdominal muscle strengthening exercises are routinely recommended by physical therapists to correct faulty standing posture in patients with CLBP. These recommendations are often based on assessment of standing posture. We urge physical therapists to avoid prescribing therapeutic exercise programs of muscle strengthening of abdominal muscles in patients with CLBP based solely on assessment of relaxed standing posture.”

In conclusion, it appears that static postures tell us little.  If you have high success with its assessment and treatment, I guess you can keep using it…but for me, I have moved forward…

Fedorak C, Ashworth N, et al. Reliability of the visual assessment of cervical and lumbar lordosis: how good are we? Spine 2003; 28: 1857-1859.

Roffey DM, Wai EK, Bishop P. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. The Spine Journal 2010: 10; 89-99.

Edmondston SJ, Chan HY, Ngai GC, et al. Postural neck pain: An investigation of habitual sitting posture, perception of ‘good’ posture, and cervicothoracic kinaesthesia. Manual Therapy 2007: 12; 363-371.

 Youdas JW,  Garrett TR,  Egan KS, et al. Lumbar Lordosis and Pelvic Inclination in Adults With Chronic Low Back Pain. Physical Therapy2000: 80; 261-275.

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35 replies »

  1. I think you make an interesting point but I personally am not going to “move on” from a simple assessment technique which can often teach patients a great deal about inappropriate joint loading.
    Where I tend to agree with you is with our preconceived notion of how a postural “type” means a certain set of muscles must be stretched and strengthened. Each patient needs to be assessed and treated individually with close attention to their mechanism of injury and their psycho-social factors. Nevertheless particularly wrt tendinopathies of the hip area long term cure is rare without correction of underlying postural dysfunction which ofter can be easily assessed with the use of a plumb line/bob.
    Have a look at this article from Manual Therapy reproduced on this web site with multiple articles related to postural assessments.

    http://dralisongrimaldi.com/index.php/publishedpapers/14-assessing-lateral-stability-of-the-hip-and-pelvis

    • Great article, Thanks. I feel we really need to move forward in PT from static postural assessment. If someone is holding a lordosis and is in pain, it has nothing to do with “weak abdominals”. Their brain for whatever reason has come to the conclusion that this is the protective strategy of choice. This may not be appropriate and may need help to change that protective strategy but telling them they are “weak” and have “bad posture” to me serves no purpose, and could it have unintended consequences?

  2. Good review, Joe. An additional thought:
    during an assessment of a patient in pain, the clinical environment, the presence of the practitioner, the pre-existing expectations of the patient, the expectations of the practitioner and the “tools” of assessment (like a plumb-line) are all influential variables on both the patient’s presentation of pain and posture, as on the therapist’s perceptions and measurements. PLUS: the assessment is only a “slice in time” – its findings are no reliable reflection on the other 23 1/2 hours of the patient’s day.

    Sharon, there is a problem with the assumption that joint loading or muscle imbalance issues are a CAUSE of the problem; there are simply too many asymmetries in normal life in many people that do not tresult in painful conditions. The study you linked to does not identify the imbalance as a cause of the problem – just that there is a correlation. Helping people move better (with less pain) is still the target, but we can not determine what is “correct” posture for any individual.

  3. Look at the total picture. Lots of people have horrendous posture and no pain. Some people have great posture and pain. Assess and treat appropriately. We are all individuals and so are the patients. Use all your knowledge and keep taking in new so that you get the results you want with your patients. That means scan and biomechanically assess every patient so you get a better chance of correcting all the contributing factors to their “condition” .Or if injured traumatically, assessing and treating all the factors that could be putting abnormal load on the part (s). Where you feel the pain may be ” a long way from the heart”.NO cookie cutters please.

  4. Traditionally with my training in PT school I was a follower of needing to improve posture to decrease inappropriate joint loading. But as I think further and deeper, how do I define and measure “inappropriate”? One example would be when someone runs we know they put more stress and load through the knee joint. But long term studies show runners with no greater arthritic changes in their knees compared to those that don’t run. So as a whole for these people the increase joint loading does not appear to be inappropriate. Simple use of Wolff’s Law explains why this might be the case (something else I learned early in PT school, but for some reason did not apply posture/biomechanical load and it together – maybe what I see as inappropriate is how they have conditioned themself slowly over the years, thus it is of no risk to them).

    Now I have no argument to change someone’s positions if they complain of sitting with their head turned one way for a couple of hours and their neck gets sore, but as soon as they move it differently it feels better. Yes, that mechanical load on the tissues may be too much and moving out of the static position might be wise and then slowly, gradually build a tolerance of it (if it is needed for their function). Also the runner who comes in saying their knees hurt and I find they increased their mileage from 20 to 40 miles in a week, I might suggest they make a more gradual progression with mileage.

    Great post Joe, and yes since it is hard for me to objectively measure or know what is “inappropriate” for a specific individual in many situations, I agree lets drop the plumb line in PT and let the surveyors and carpenters use it.

  5. Let’s not forget that we can use static posture to help both the patient/client and the trainer/therapist understand the differences in functional anatomy when the body is vertical in the presence of gravity versus laying on a table. With the way anatomy is still taught, many professionals need to be introduced in a static environment before they can comprehend movement assessments. How do you assess a squat when you think the hamstrings are flexing the knee?

  6. I believe that static assessment in any plane or position is quite unnecessary. At least in the treatment of painful conditions (the reason why many patients seek our services). I believe the assessment of movement and provocation gives us more useful information. Identifying “normal” vs. “abnormal” is quite a complex task and unless we have a pre-injury baseline, how do we determine what we are seeing? And then, how do we determine what we are seeing is contributory to our patient’s condition? I believe static postural assessments give us a false sense of diagnostic certainty.

  7. Dropped the plumb line, but I still do static posture assessment. I do so quickly, and only as a means of identifying significant asymmetry, indicating other assessments or establishing Re-Eval criteria.. Sensory deprivation w static posture assessments is fun as it may reveal proprioceptive compensations (rotations). I rely more on dynamic assessments (when they are not aware that I am looking); such as gait and workplace ergonomics, watching them get out of a car to come inside, standing in the hall (talking), shifting in a chair, ..etc. ROM testing, passive and active, active/resisted muscle testing.

    • Not quite sure what you mean Bobby. Can you discuss further? What is a significant (vs. insignificant) asymmetry? What are propriceptive compensations (rotations)? I do agree completely that dynamic assessments are much more pertinent.

  8. What to say then about shirley sharmann´s approach?
    I think a lot of important things have been adressed so far, but deviations regarting the normal for the person can be checked checking diferences between limbs and correlating with strenght and flexibility.

    • I do not put alot of weight in Shirley Sharmann’s work. I am very familiar with her and am grateful for her attempt to better our profession. She recently gave a lecture at IFOMPT on the relationship between the hip flexibility and LBP. I would classify her with DonTigney and Cibulka. They worked their entire lives attempting to create a causative link between biomechanics and pain. Unfortunately, there does not appear to be one. But it’s not their fault. We are just simply fortunate to now have better abilities to share research and view anatomical and neurological structures.

      • There is zero research showing a causative relationship between the two. Mechanical deformation may stimulate nociceptors which send danger info to the brain which may cause it to send an output of pain. But nociception is not sufficient for the experience of pain.

      • The pain research is truly game changing in a lot of ways. And letting go of old beliefs is challenging. IMHO, much of the interventions in the past worked and continues to work but maybe not for the reasons we always believed. Nociception alone is not sufficient for the experience of pain, but isn’t the stimulation of nociceptors (along with other sensory input) one of the fundamental pieces of the “input” pie that leads to pain perception for many? If the nociceptors open the door to other output mechanisms that enhance the pain experience, doesn’t it make sense to remove the mechanical stress starting that cascade? And if it were not, why do we bother designing therapies or exercise programs that seek to help people move better? Thanks for all the thought provoking information.

      • Joesph, to say Shirley Sharman lacks the ability or environment to view research or anatomical models like the rest of us is quite ignorant. She is a professor at a research intensive university…she has access to more research than most. While I agree with your assertion that structure has a limited (not obsolete) ability to dictate pain, I believe that the way we move is not simply a matter of neural programing. How do we explain studies in which nerve blocks to specific anatomical structures relieve pain? How do we explain how PRP therapy works in some clients with achillies or lateral epicondyle tendonosis? How do we explain a client who has trouble turning his head to one direction with pain after sleeping in an awkward position and after a manipulation to the area, the client has full pain free ROM (within seconds)? These are just questions I have as I have seen this happen time and time again in my clinic and I don’t know how else to rationalize it other than a structural or positional fault was relieved, which subsequently decreased pain or the perception of pain.

        Thank you for your time in writing these great blogs!

  9. So if you have moved on, how do you assess? Respectfully, I think static postural assessment is very useful as a starting point for assessment and treatment and as a client education tool. But I would also suggest that what we should be assessing is alignment, not posture. The research may suggest a lack of correlation between
    “posture” and pain, but pain does not tell the whole story of health….

  10. Hey Janet,
    Why do the majority of patients seek our services? Pain. Patients generally hurt with some form of movement. In terms of my examination, I am most concerned about what reproduces my patients chief complaint. For example, if a patient experiences pain at 150 degrees of shoulder flexion, I know that for whatever reason, the brain suspects there is a threat, or potential threat, to the tissues in the shoulder, at this point. So we need to restructure how the brain perceives this motion. A static assessment tells me nothing about how someone moves. I rarely ever see patients that state, “it hurts when I sit relaxed in this slumped position”. Anyone would have the subconscious intuition to move out of this position.

    That stated, I am curious by what you mean about alignment…

  11. I’m not a PT but I’m studying RMT and I really don’t know what to think. My biggest issue was deformity and loss of function – *not* pain. If just one knowledgeable person had believed me and properly checked up on my complaints of changed body shape / posture then I might have spent a little less than seven years with my sternum dislocated (manubrium flipped SC joint forward). As it was, my suddenly severe kyphosis (main symptom) was *always* dismissed as irrelevant and nobody ever did a full physical assessment, no matter their profession (PT/Chiro/OT/MO). Anecdotally, dislocated MSJ’s and ‘popping sternums’ are more common than you’d think. I’m putting this out there because I’d hate to see it happen to somebody else.

  12. Nice thinking Anthony. You are heading along the right track. Sensory information (mechical, thermal, chemical) most definately can stimulate nociception and this is important to understand. But inputs such as a context, environment, bad thoughts, words, hormonal changes, etc. can have just as much of an effect in sending an output of pain. So if a knife is sticking out of the arm, then yes, remove that knife. But with us having so much anatomical variablity, how do we detect individual norms if we are meeting a person after they have developed symptoms. How do we know if a forward head, rounded shoulder, etc. isn’t how they are put together? I have an issue with measuring, assessing and attempting to correct “static” positions bc in relation to pain, it means nothing. I have no issue with movement therapies (which do not provoke symptoms). We have good research to support “motion is lotion” and the effects that it has on the brain.

  13. Joe: interesting comments, but if I remember correctly, Lorimer, in his book, affirms that he is not talking about throwing away mechanical assessments, but complementing them with a comprehensive view of pain and its behavior. Many Manual Therapists support the idea of doing very brief static posture assessment, just looking for marked differences (and Yes, you can question what this means, but there is also a bit of ¨common sense ¨in science too) .
    Stanley Paris affirms that ¨Physical Therapy is not just a science, but it is also an art¨, and believe me, I´m proud of it.(please read well, he is just saying…. ¨it is also…
    Vladimir Janda, supports the use of Standing Posture Assessment from the Muscular Standpoint, which he proved to be very reliable and time saving because it will guide the therapists to specific areas.
    Karel Lewit warns us with his ¨He who treats pain is often lost, and so is the patient¨
    With all that being said, I truly believe that Lorimer´s and Dave´s info have enlighted the Physical Therapy field, but we should use that info to better our profession and not just to discard previous info that has been scientifically validated ( and yes, there is a lot of scientific studies!!)
    Summarizing, I think you have a good point, your statements sound reasonable . Just wanted to add that there is a lot of ¨evidence based manual therapy¨that can definetily be utilized as well. (and yes, dynamic testing and provocation may be important info to consider!!)¨
    I´m just adding this so we don´t end up like in the 90´s when people misinterpreted the Australian Approach for stabilization thinking that the only muscle that had to be re- trained for spinal stab was the Tr A. Hodges affirmed that they never meant that. I´m totally sure that Lorimer said the same!!( I heard it from him)

  14. Joe,
    Nice post and sorry I am a bit late to this. I have been doing a literature review on the relationship between static posture and shoulder impingement syndrome. There are actually quite a few studies which have looked at this. There does seem to be a consistent correlation between scapular biomechanics and impingement (chicken or egg who knows) however cervical, scapular and thoracic static posture does not appear to be correlated with pain or with scapular dyskinesia. I did come across a few studies which showed a relationship between posture and TMD and inter-scapular pain. I do feel that posture is at best a very small part of the puzzle and we should not waste much time on it.

  15. I’ve been enjoying the discussion on your website. Well done! On to static assessment. First of all, if the reliability of assessment is poor (or fair) from person to person, then it’s already a bad test. Second, even if your assessment is an accurate one, what does it tell you? Does it tell you what tissues are stressed? Maybe. Does it matter what tissues are stressed? Maybe. I think general posture assessment is like MRI’s and other diagnostic (and special) tests. It may give you a general idea of what’s going on but whether it really tells you what you NEED to know is debatable. I think postural issues matter if your body’s choice of posture activates a neurotag for pain. Whether it’s good posture or bad posture is (in my opinion) fairly insignificant. I’ve often wondered how much of what I do with patients helps because it makes movement patterns “right” or just different. If a different posture improves pain, is it because of the change in mechanical pressure, etc. or is it simply that it alters the neurotag that results in the brain not activating a pain response. I think it’s probably a little of the former, but more of the latter (it has to start with the brain).

  16. Aaron: I go back to what the great Vladimir Janda used to say. Static posture assessment, particularly from the muscular stand point, gives you a baseline of info that could save you time in your total assessment but overall, will guide you to the regions where you could focus your attention on. It may be your wake up call that something is not right in a specific region of the body. Of course, standing posture assessment does not give you all the info you need from an evaluation . It may be just your starting point. So… yes , it does give you the info that you need, related to that particular test or assessment. And of course, we need to add the Neuroscience into our treatment philosophy but at the same time, even Lorimer is telling us that Neuroscience is just a piece of the entire picture. Regards,David.

  17. That never made a lot of sense for me either, but still it seems to be common recommendation, at least here in Quebec, Canada. I personally got better results with restoring normal range of motion in movements, and improving posture as a byproduct, than the other way around. If pain is still there, at least my patient moves better, which sounds like a victory by itself.

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