The influence of structure on back pain is a discussion I have had twice in the last 3 days.

I would not describe myself as an expert in this area but this area of discussion does leave me a little confused and I do take an interest in it, especially with the whole ‘forgetting the bio in the BPS’ thing.

These are just some thoughts and data, this is certainly not a comprehensive literature review, just information I have been exposed to and to be honest leave me more uncertain than certain.

Undoubtably the disc can be a source of nociception and relevant in back pain. The plausability is not in question here.

My key questions (not really answered yet) are:

1) How do we reliably identify discogenic back pain clinically?
2) How does this influence our management?

WARNING - the data below is likely to leave things much murkier than clear!!!

Prevalence of disc related factors in LBP

So firstly we see that disc degeneration is more prevalent in those with back pain.

MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis

We also see that more findings (3 or more) on an MRI report were more strongly associated with LBP than a single finding.

Is the Number of Different MRI Findings More Strongly Associated With Low Back Pain Than Single MRI Findings?

Here we see those with acute back pain are more likely to have disc herniations

Magnetic Resonance Findings of Acute Severe Lower Back Pain

But we also see lots of the same signs in those with no pain

Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations

Again a high prevalence of the same signs in asymptomatic populations.

A review of the value of MRI signs in low back pain

People with previous back pain also had increased MRI findings but no current pain.

The relationship between findings on magnetic resonance imaging and previous history of low back pain

MRI findings also do not seem to be predictive of back pain.

Does magnetic resonance imaging predict future low back pain? A systematic review

Changes in MRI are also similar in symptomatic and asymptomatic populations

Prospective Comparison of Changes in Lumbar Spine MRI Findings over Time between Individuals with Acute Low Back Pain and Controls: An Exploratory Study

So maybe we need to think more about relevance than prevalence here? If both groups can have MRI findings then we cannot just assume.

Do symptoms of lower back pain correlate with structure?

These papers below would suggest it is not that simple to correlate the symptoms that people experience compared to imaging. Again this suggests that if there is nociception from the disc it is not the only factor at play.

Do more MRI findings imply worse disability or more intense low backpain?

Associations between back pain history and lumbar MRI findings

Back pain and MRI changes in the thoraco-lumbar spine of young elite Mogul skiers

The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis


It does appear to be difficult to diagnose discogenic pain with 90% being labelled as non specific. So we know it can be prevalent but it is difficult to find if it is relevant for your patient. Ultimately we need to be able to identify clinically to make the link in my opinion.

Diagnostic triage for low back pain: a practical approach for primary care

These are some recent clinical classification guidelines.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

There is some support for centralisation in identifying discogenic pain.

Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power

This paper is pretty certain in being able to identify discogenic pain

Lumbar discogenic pain: state-of-the-art review

This paper suggests that internal disc disruption is not a real thing!

Diagnostic criteria for the clinical syndrome of internal disc disruption: Are they reliable?

How does this change management?

It was suggested to me that we would treat an annular sprain much the same as we would a sprained ankle. This would be through the concept of optimal or tolerable loading and could be done both via the magnitude of load and manipulating the load different movements might place on the disc through spinal kinematics.

I think this sounds fair however it brings us to the second point I raised of does this information make a big change in the management of LBP. We could treat a non specific LBP in a similar way so again I am left a little confused.

Over the longer term for conditions such as disc degeneration the famous Battie twin study would suggest loading has limited influence.

The Twin Spine Study: contributions to a changing view of disc degeneration

We can't draw to many conclusions from these two papers below, as they are observational, but perhaps they tell us that activity is not detrimental and MIGHT BE beneficial.

In Vivo Correlates Between Daily Physical Activity and Intervertebral Disc

Running exercise strengthens the intervertebral disc



So the real question should be, how specific should we be with our exercise prescription?

(Now this could have turned into an epic blog, but I have decided to keep it brief and readable!)


Now that’s a pretty emphatic statement so I should probably add a bit of nuance to that.

For some people the term specific means that we should use a SPECIFIC exercise for a SPECIFIC problem.

The world of therapy is littered with exercises that have been held up as the ‘best’ exercise to fix a certain issue and not achieved that status, think TvA activation exercises for back pain or VMO exercise for knee pain. Being specific in this way does not appear to be warranted with the current evidence base we have.

We could also be specific to some form of physical quality like strength or range of movement. We see that in many cases when it comes to MSK pain going after a specific physical quality also does not seem to yield better results, there ARE a couple of examples of when being specific is important and I will discuss those later.

I might be bold and stick my neck out and say that non specific pain (meaning we cannot pinpoint the source), of which we seem to have a bunch of around the body, probably needs a non specific approach to exercise. This means that we cannot strongly suggest a singular exercise or a type of exercise that focuses on a physical/biomotor quality.

So why the need for Specificity?

So everything I have said so far may seem to point towards there being no real need to be specific. Does that mean that we can just give someone any old exercise and expect to see a positive result from it?

I don’t think so.

Any application of exercise should come with some form of reasoning and we should start with the end in mind.

What SPECIFIC effect do we want from our exercise?

This will be SPECIFIC to the person and their current issue or goal. This means that the reasoning approach is always specific but the application may not always be the same.

So rather than be SPECIFIC to a type of exercise or presentation we are being SPECIFIC to the PERSON standing in front of us.

WHAT do we want?

Screen Shot 2017 04 10 At 17.33.20

There are many different outcomes that we may want to achieve from our application of exercise and we find we can influence lots of different elements of human function.

To make things a bit simpler and more organised we could make some broad categories.


This could be tolerance of a specific tissue such as a tendon or muscle although we still have not quite worked out the relationship between pathology and pain here.

There may also be clearly defined scenarios where we do see the need for specific biomotor qualities, such as strength needing to be addressed post operatively.


Pain relief maybe another specific outcome that you want to achieve from your exercise prescription.

It seems here that lots of types of exercise may create analgesic effects. Isometrics are the flavour of the month at the moment but both strength training and cardio training also have the potential to create analgesic responses.

I am still slightly on the fence about the usefulness of short term responses for all but I can see a clinical need with some groups of patients.


As we start to move away from a tissue focused view of exercise and movement the concept of beliefs around exercise become much more important

Concepts such as fear avoidance and exposure based therapies are starting to gain traction, and rightly so, especially as their role in actually getting people moving is starting to be appreciated more and more.

We might have to be very SPECIFIC to a movement but that movement is probably very SPECIFC to the individual as well.


It might not matter what the exercise or its aims are if it doesn’t get done in the first place.

This is a great example of when non specific is really quite specific.

We may have to be specific in

  • Location
  • Type of equipment
  • Preferences & enjoyment

To get someone moving again.


It has been hard to pin down many SPECIFIC movement ‘problems’ that we reliably see as a cause for pain.

Our understanding of the mechanisms behind the pain experience are broadening and we see modern concepts such as the decoupling of SPECIFIC movements from pain responses as a plausible reason for using a movement based approach but again these seem to be quite SPECIFIC to the individual.

Variability that is either too high OR too low might be relevant to pain, maintenance of pain and injury. Or not! Who knows.

It might be that just MOVING is what many people need!

Being specific – Where’s your data!

This does not mean that there are NO specifics we should aim for across people but they DO need to be clearly defined. An example here might be return to play for ACLR rehab. Better outcomes have been shown if patients achieve RTP markers of almost equal, within 10%, of quadriceps strength and also hop performance. We also see the specific use of eccentric contractions with the prevention of hamstring injuries over concentric strength work.

The key here is if you ARE being specific that you have some form of data to back it up.

Remain vigilant to the specific response

All exercise gives individual responses, its not just fire and forget. Lots of exercise research is based around comparing the means of two different groups to look for a statistical significant difference or variation between the two groups.

While this type of analysis does point towards a trend for an effect, in reality it gives us little idea about individual responses to exercise so it is important to monitor someone’s response rather than just expect your reasoning process to have a successful outcome.

An exercise could make someone better, worse or simply have no difference. It is important to know that many exercise interventions don’t achieve spectacular results. The actual effect is often around the minimal clinically important difference (MCID). The MCID is smallest difference that a patient is likely to see as important to them. Although this number varies across studies is generally around 2 points on a 11 point 0-10 VAS scale.

We must always be prepared to adjust the exercise type or dosage based on the SPECIFIC response from the patient.

Summing up

  • We always need to be SPECIFIC
  • Not always in the same way
  • Always ask "what do we want?" from the exercise
  • Lots of different effects across the BPS spectrum
  • Want to be specific? Have data!
  • Always remain vigilant to the effectiveness of your exercise

Exercise is great, we know this, right?

Well sort of.

Many people know exercise is good for us on a general level, but the question is, do they know it’s right for them on an individual level and is it the right fix for their problem?

This is an entirely different proposition, applying that general information to the person. This idea that these things are good for us can be quite vague, one of those things we may have glanced over in a newspaper or half heard on the news whilst eating our cornflakes.

People also build up ideas about what is the correct treatment for them. This can be from their own in depth research on the internet (right!), what they have picked up from friends and family or from previous treatment with a therapist. This can lead to some pretty strong ideas about what should and perhaps should not be done to help them.

These beliefs don’t always align with the best available data we have about interventions. A prime example of this is the belief that exercise risks out weight the benefits with back pain (55% of folk in New Zealand).  This stat was taken from this Darlow paper in 2016 HERE.

We know that exercise can be effective with back pain, certainly not a magic bullet, but one of the best things we have at our disposable within a comprehensive treatment plan, especially as it is low cost and low risk too.

Beliefs and expectations

Our beliefs drive our expectations and actions. Predicted expectations are gaining weight as a prognostic factor in recovery over the past decade. They may influence my participation and behaviour in a treatment plan that will ultimately affect the outcome.  If I don’t believe in something I am much less likely to do it.

How can we combat this? Well in my opinion the best tool we have is good quality information we can use to combat the beliefs that may hold people back. A key to start affecting beliefs, again in my opinion, is not to challenge to firmly but inform people using well-evidenced information.One of my favourite one liners is “ That’s what we used to think but we are learning new things all the time, the latest research suggests….”

Here are some small titbits of information that we can use to start informing our patients and clients about the role of exercise in pain AND health, which of course ultimately affects pain too!

Remember that giving people information is really designed to change behaviour rather than just show how smart you are so monitoring what happens is pretty important.

1. Exercise is one of the BEST well EVIDENCE interventions we have for MSK pain

This paper HERE from 2017 in PLOS one shows moderate to strong effectiveness of exercise as an intervention for many MSK issues. This is in contrast to the belief that things need to be zapped, needled or popped back into place.

My therapist only gave me some exercises. Yep. Because they followed the evidence!

2. Exercise won’t make your body WORSE

So many people see the body as a bit of machinery. The more it works the more the parts need replacing. Is this true? Absolutely NOT. The body is an organic organism that adapts both positively and negatively to stimulus. The more active we are (within reason) the stronger we become. The less active, well…..

A classic common belief is that our invertible discs wear out the more we use them. This classic study from Battie HERE (2009) looked at twins to determine the major contributors to disc degeneration. They suggest that the  “commonly held view that disc degeneration is primarily a result of ageing and "wear and tear" from mechanical insults and injuries was not supported by this series of studies”

This study HERE from 2017 found that if you have a rotator cuff tear, the tear getting worse did not appear to be simply related to activity levels. In fact they  suggest pain development is actually associated with LOWER activity levels.

If I had a pound for every time it has been suggested to me that running damages the knees then I would be a rich man. A study of marathon runners HERE showed that they had LESS meniscal abnormalities than non runners.

3. Exercise might actually make the discs in your back healthier!

Two recent studies have shown a POSITIVE effect of activity on intervertebral discs. Firstly this study HERE from 2017 showed that MORE vigorous activity was associated with BETTER disc health on MRI.

Secondly, in this paper from 2016 HERE. Runners were shown to have intervertebral discs that had increase hypertrophy compared to the non athletic group. The authors suggest that running actually strengthens the discs, whether we can infer a causal relationship here is unclear but this goes against activity causing wear and tear which is a common belief.

4. Activity is a pain killer

This study HERE showed that older adults who were MORE active also had better endogenous pain inhibitory mechanisms when their conditioned pain modulation (CPM) was tested. Simply put : ) this means the more active the better their natural pain killing mechanisms were. Which of course is super cool.

5. Exercise is an anti inflammatory

This study HERE showed that regular physical activity caused an increase in interlukin -10 which is an anti inflammatory cytokine that can reduce nociceptor sensitisation.

Now the caveat here is this study was performed in an animal population but as we know that there are associations between inactivity and both acute and chronic pain in humans it is a linked that potentially needs to be better explored.

6. Lack of exercise is associated with chronic pain

This large study HERE looked at the relationship between recreational exercise and chronic pain. Both older and younger folk were studied and the researchers found that for both groups exercise participation was associated with reduced chronic pain. A relationship was also present for the frequency, duration and intensity of that exercise.

7. Lack of exercise as a major cause of chronic diseases.

This comprehensive paper HERE makes a case for a lack of exercise being a primary prevention against 35 chronic conditions suffered by us poor humans. This goes beyond what most of us involved in the musculoskeletal field would have to deal with but also shows the importance of exercise for systemic health too.

8. Its involved in mental health as well.

We are understanding more and more that the mind and the body cannot really be separated. Physical health and mental health are interlinked in the human being and guess what…..exercise plays a role in improving mental health too. This paper HERE explores the mechanisms that may relate to mental health and exercise.

This randomised control trial looked at aerobic exercise and a variety of measures of psychological health HERE. The authors found significant group differences that favoured the exercise group.

9. You want to live longer right?

Strength training in this paper HERE was found to have a significant association with decreased mortality in adults over 65. BUT only a minority of this age group actually meet the current guidelines.

10. Have a healthier heart

This prospective study of 15 years duration HERE found that physical activity was a predictor of cardiovascular disease.

Summing up

There are a whole bunch of others studies that relate to these topics but I just picked a few. I think it demonstrates that physical activity and exercise have an effect on us on a number of different levels, from the heart to the head to pain as well.

  • Do it
  • Do it
  • Do it
  • Do it

Here is a short video I did on the Rethinking physiotherapy Facebook page on Applying pain science education. ENJOY!!!!

Pain education is a valuable tool for some, but certainly not all, patients. It can help to provide a narrative or explanation for problems that may remain unexplained by ‘traditional’ medicine or therapy.

This paper HERE regarding chronic lower back pain explores what people are looking for from a visit to a therapist.

more than 90% of patients expected a physical examination, tests or investigations, a diagnosis, reassurance and advice, and clear explanations of causation, symptom management”

How tough is this in many instances with no clear diagnosis or causation available?

Up to 90% of back pain is described as ‘non specific’ for this very reason. We know that uncertainty is a big deal for many patients. Mishel first proposed this in the “theory of uncertainty of illness” HERE.

Carroll's paper HERE How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury” also discusses the process of diagnosis, uncertainty and the subsequent effect on expectations of recovery.

But although data suggests pain education can help it can also be very tough to deliver.

This quote from Louis Gifford sums it up nicely.

"The patient that learned from their pain explaining therapist that their pain didn't really mean anything, who suddenly got out of the chair, went home and went riding their bike for the first time in 5 years...just doesn't really exist!”

So how can we improve the delivery of pain education?

A question I often ponder is have we replaced anatomy with neurobiology? Do we now bombard people with complex processes involving brains, nerves and receptors rather than complex biomechanical stories? How much neurobiology or neuroscience is actually required?

In some cases certainly it will be useful, but in many cases maybe it could actually hinder. This does not mean that some of the key concepts such as plasticity, sensitization and the brains role in pain are not important but maybe the minutia of information that can be focused on is unnecessary.

Perhaps we can apply some of the information in this paper HERE. Simplifying MRI reports appears to have a positive effect on how they are received. This may also apply to the delivery of pain education. What does nociception or Ion channel mean to a patient? It could end up very similar to VOMIT (Victims of Medical Imaging Technology) HERE if poorly delivered.

Should the focus now be on the delivery and context of information rather than the information itself?


I thought it might be nice to get some other opinions on some of the key elements that go into making successful pain education and reached out to colleagues from around the world, using social media, to pitch in.

Some of the key components I already advocate, but I must admit some others I had not considered and provide valuable food for thought for myself and perhaps also the wider therapeutic community.

I was pleasantly surprised by the elements discussed, almost none related to the actual information itself but instead on the delivery and thought process involved.

Here they are!



The most consistent point made by the contributors as a whole was listening.

Listening is a key clinical tool. Although pain education is often thought of as the delivery of information, it should start with listening. I think this is advocated on many fronts but as we know patients can often be interrupted pretty quickly HERE and this is always worth keeping in mind.

The desire to be listened to also appears to be valued from a patient perspective and helps to build therapeutic alliance HERE. This is probably vital for those receiving and processing the information. delivered.

This is a good paper on ‘listening as therapy’ HERE


A couple of patients also contributed to the discussion and they felt that someone listening to and validating their experiences was a big part of their recovery. This also ties into the paper above regarding a patient’s perspective. If symptoms cannot be ‘medically’ explained or solved by traditional interventions, then patients may feel that they are being seen to ‘make it up’ or exaggerate their painful experience. All pain is real and although it can often be hard to describe it is also exactly the way that someone says it is. It cannot be anything else!


Another of the key points consistently put forward was about individualizing the delivery and placing into a relevant context. Now I personally have a bias for placing pain education in context with someone’s current situation. By weaving it into their story and using their painful examples to tie in some of the key concepts I think we are more likely to get some elements of comprehension.

This fits well with the key component of listening. Without listening we cannot place the information in the context of the patients narrative.

The question is, is this more effective than information generically delivered? I just don’t know. I think this would be an interesting comparison to study.


One thing I must admit to NOT asking was simply “do you want to know more about pain?” This was brought up by a number of people. This may avoid the very real problem of ramming pain science where it is not wanted. Pain science should be judiciously applied where it is needed AND wanted rather than a therapist dropping knowledge bombs expecting an instant epiphany.

It is not a passive exchange

Remember there are two equal people involved in this. It is not simply a teacher pupil relationship. Patients lived experiences are also important. The therapist can also learn from the patient, especially when it comes to the patient experiences. Perhaps it should be seen as a journey by two people to find mutual meaning in a negative situation rather than simply an educational experience.

Pain science is a way of thinking not an intervention

One of the criticisms that I have seen recently of the application of pain education is that it is seen as a standalone intervention. So rather than bombarding people with statements or analogies that have been previously heard for explaining pain, the concepts and ideas should affect the way we reason, interact, explain and apply the treatment provided.

Experiences are as powerful as talking

It’s not just about talking; doing is also a powerful educator. Perhaps sometimes talking is needed before and after the doing, but without the actual doing we cannot ‘prove’ the point. Beliefs about the body are a good example of this. Without SEEING or FEELING a different, positive outcome to that expected, potentially a number of times, a belief may remain in place.

Again listening is key. What are the key experiences that need to be reconceptualised in a physical sense as well as a cognitive sense.

Find out HOW your education has been interpreted

As with any part of the therapy process, pain education has the potential to have a NEGATIVE outcome as well as a positive one. We may well baffle people with talk of brains and outputs etc and HOW they interpret this information is the arbiter of success, however well meaning or comprehensive the input by the therapist.

This may boil down to wording, health literacy and therapeutic alliance. The list of potential influencers is endless, but essentially the ability to mitigate any negative effects could be dependent on simply asking!

We may be able to influence this interpretation by being clear and concise, using bite sized chunks of information, avoiding confrontation regarding beliefs and also avoiding negative or long winded medical or anatomical jargon and terms.

Reflective questioning

Don't just providing statements, also use reflective questioning. This may help to facilitate understanding and apply this new information to their own personal experiences and think critically about some of the beliefs they may hold.

Lets say someone has a negative belief regarding about their back because of a slipped disk a number of years ago. We could suggest that structure and symptoms don’t always display a consistent relationship. We could follow this up by asking if their symptoms come and go (as long term back pain generally does) and would this be a sole cause if the ‘slipped’ disc remained a constant.

Of course this is just some opinion/s but collectively they could be valuable!

Key points

  • People are looking for answers
  • Uncertainty makes things worse
  • Pain education may provide some explanation
  • It is tough and often fails

Some things may make it more effective

  • Listening
  • Validation
  • Individualisation
  • Asking If it is wanted/needed
  • It is not a passive exchange
  • Pain science is a way of thinking not an intervention
  • Experience is as powerful as talking.
  • Find out HOW your education has been interpreted
  • Reflective questioning

Here is another webinar! This time for the Pain Masterminds Network.

The subject is 'Exercise and clinical reasoning - More than sets and reps'

I am taking a look at moving beyond the tissue and capacity model of therapeutic exercise.

Below is the PDF of the presentation!

Pain Masterminds 1.compressed

If I had a £ for everybody that mentioned posture on social media or when they had a pain problem…… well lets just say I would be a pretty rich guy.

POSTURE has literally become engrained in peoples thoughts when talking about back, shoulder or neck pain even though we have a shit ton of studies that compare the postures of pain free people with those with back, shoulder or neck pain and find no real differences, this information gets regularly IGNORED.

NEVER let science get in the way of a good story, especially if it’s on the interwebs!

In fact I have written about posture a few times before : )

The definitive guide to posture and pain 3 minutes flat

Do you really need your joints to be centred?

But just to kick off with a bit of science, this paper HERE from 2016 found NO significant difference in lumbar lordosis (spinal curve) between people with back pain and those without.

This is super important. HOW can we blame something that we see in people WITHOUT pain as a cause of pain for those that do?

I will just let that sink in……

What are you measuring?

So in this blog we are going to explore a few questions related to how we assess posture and if they are actually scientifically VALID, because if you don't have a good measure to begin with then it is pretty tough to blame something for the problem.

The first piece of ACTUAL EVIDENCE, something often missing in the posture debate, looks at the measurement of STANDING LUMBAR LORDOSIS (the curve in the back often blamed for back pain) and this assessment is something that is performed in treatment rooms and gyms the world over.

The idea is that an increase (and sometimes decrease) in lumbar curve increases back pain and is often coupled with the idea that the tilt of the pelvis has an influence on the size of the lumbar curve, even though lumbar curves do not seem to be much of a factor in lower back pain anyway (see the SCIENCE above : )

Way back in 1990 this was explored by Heino et al HERE and they found that the angle of someones pelvic tilt and their lumbar curve do not simply correlate! So looking at the position of the pelvis tells us very little about what is occurring at the lumbar spine, which is much harder to measure. A very similar study HERE from before this in 1987 also threw up the same result  but this BS is still being taught today.

Anyway, back to the standing measurement paper HERE. The authors explored the variability in standing posture of 400 people, 332 without pain and 83 with low back pain, and they found that each time we stand we do it in a slightly different way.

The authors in their words state standing is highly individual and poorly reproducible”.

So why does this matter?

Well simply put, which posture are you ACTUALLY measuring with your postural assessment. One may show an increase in lordosis, another less so.

I have some questions related to how we interpret postural assessments in light of this information.

  • Which of these postures is related to the problem?
  • How many times do you measure and do you average?
  • What are you comparing against to determine if the curve is too much or not enough?

The authors highlight a good point that the lack of consistency in standing posture may actually lead to the “wrong diagnosis and possibly unnecessary treatment”.

If you focus on something that is not an issue you do not focus on something else that might be or be blinded to the fact that it is not working or only works transiently (potentially why so much back pain is persistent).

What people actually use in their everyday lives might also be different to what is measured in the clinic or gym. A clinic or gym measure could be described as a ‘snapshot’ and this study HERE compared this ‘snapshot’ to what was actually used on a daily basis by the study participants.

The authors found that on average whilst standing, as most postural assessments are, there was a 33.3° lumbar lordosis but the average used over a 24hr period was only 8°, a huge difference!

So the ‘snapshot’ postural assessment would not really inform us very well about how much lordosis was REALLY being used and we could overestimate the extent of the imaginary problem : )

We also have to remember these were radiological measurements and this is the clinical ‘gold standard’. Often a lordosis is measured in a much more rudimentary fashion by looking at the relationship of landmarks at the pelvis indicating a pelvic tilt and therefore change in lumbar curve, which we have already discussed as not being well related to lumbar curve! This in itself is a problem as demonstrated by Preece in 2008 HERE as pelvic morphology is also VARIABLE leading to incorrect measures.

These results suggest that variations in pelvic morphology may significantly influence measures of pelvic tilt and innominate rotational asymmetry”

 Here is the distribution of side to side difference of the ASIS-PSIS relationship (used to assess pelvic tilt), we can see it is skewed to the right side meaning it is more anteriorly tilted at a BONY level.

Jmmt0016 0113 F04

So it might be that we are really bad at measuring something that doesn’t matter that much. OUCH

Are you biased?

Another important question for those that assess posture is……are you MORE inclined to see an ‘abnormality’ in posture when you know pain is present?

This paper HERE would suggest so  Here the authors looked at scapular dyskinesis or abnormal posture and movement of the shoulder blade, which is often proposed as a CAUSE of shoulder pain.

They compared 67 people with shoulder pain and 68 without and firstly found that there was no difference in shoulder posture or motion between those with pain and those without.

Fascinatingly though when the assessors were aware that they were assessing someone IN PAIN, they reported a greater prevalence of a postural or movement problem. This shows a bias towards to finding an ‘abnormality’ to blame when there is pain, even though there was NO MORE ‘abnormality’ in those with pain than without.

The authors also suggest that scapular dyskinesis actually represents normal variability between humans! Perhaps if they assessed it multiple times it would throw up different measures each time?! It is important to remember we have no scientifically defined ‘good posture’ to base deviations from in the first place.

How do healthy people sit?

Another question is how do people without back pain actually behave? They must have great daily posture right? Well actually NO.

This paper HERE shows that asymptomatic folk , 50 of them, when seating actually SLUMP. In 10-min sitting, spinal angles flexed 24 deg at lumbar and 12 deg at thoracolumbar regions relative to standing posture. But this slumping does not seem to cause them problems.

So changes in our spinal curves seem to be fairly unrelated to pain as we can see below.

PowerPoint Presentation


So if posture does not really correlate with pain, what does it correlate with?

Well this paper HERE shows that cervical spine alignment changes actually correlate with age. This study split the participants into 4 groups determined by age. They found that the measures of the angles of the neck all correlated with the increasing age range of the 4 groups.

Key point to remember here is that all the participants, 120 of them, had no pain. In fact the exclusion criteria here was pretty rigorous and the authors actually excluded 64 people, so 1/3 of the original sample, for having current or previous pain.

So simply put, as we get older our posture becomes ‘worse’ or perhaps better put our posture increases....BUT and a this a big BUT, this does not seem to cause MORE pain.

To sum up it does not seem as simple as ‘bad’ posture = pain whatever you read or are told in a bar, gym or clinic room.

Key take homes

  • People IN pain DON’T have different postures to those that don’t have pain
  • Posture displays variability just like movement
  • This means your assessment may not tell you what you think it does
  • Your assessment could be biased to finding a postural ‘problem’
  • Postures used throughout the day are probably different to those being assessed
  • As we get older our posture change and this happens to people NOT in pain too

Here is a FB live lecture on adherence with lots of research discussed around this topic and a sprinkling of opinion too!

Here are the slides too! Adherence (1)

So I got my virtual buddy Paul Lagerman AKA the naked physio to come in and contribute to this post and below is our bastard lovechild offspring of a blog post : )

The video above on whales and their contribution to our planet is not only informative and enlightening but also serves as a great metaphor for our understanding of the human body.

Confused? Read on.

An argument for the continuation of whale hunting is that whales are predators that sit at the top of the food chain and consume fish. One school of thought would be if we reduce the number of predators then there will be more fish for the smart Humans to eat. Sounds simple right?

Well, actually….not so much!

The video nicely highlights the complex interaction between the whales and other inhabitants of the sea such as fish, krill and plankton. In fact what has been found is that as we reduce the number of whales so has the number of fish reduced, disturbing the homeostatic balance of the ecosystem. Interestingly, causation is not a simple correlation of reducing numbers of one thing will increase the numbers of the other.


Well as usual what seems like a simple relationship turns out to not be so simple, and the reasoning model used to come to this conclusion is well….. simply wrong.

Surprise surprise.

The whales as it turns out have a much more complex interaction with the environment so there are things that have simply NOT been considered in the simplistic model.

The whales actually bring nutrients up to the surface in the form of whale poo that are much scarcer in the upper waters and in turn help to fertilise plant plankton. They also create changes in the vertical water flow by moving up and down the water column that also has an effect on the plank plankton and enables them to thrive.

The animal plankton feed on the plant plankton that in turn feeds the smaller fish and krill and so the food chain flourishes, it moves and it flows.

So simply put more whales equals MORE fish and krill, not LESS.

Thinking about the impact of just one system in the biological world where more than one system interacts is just well plain STUPID even if it is simple and makes sense to some people. The aquatic ecosystem is multidimensional, approaching it with a unidimensional reasoning model will always have trade offs.

Remind you of another model?


The parallels with the human body are quite stark. The body is a complex system made up of many systems that interact such as the mechanical, biological and psychological. We can break it down further into the cardio vascular, muscular endocrine etc etc and all of these systems interact. The body depends on a homeostatic balance and interaction between systems similar to that of the aquatic ecosystem.

When we view the body simply as a mechanical system operating in a linear fashion, it makes complete sense that if we keep moving in a specific or repetitive way we will produce increase stress to muscles and bones that eventually will fail and cause pain, or that the knock on effect of excessive or decrease movement will cause a problem somewhere else.

Is this a bit like thinking less whales equals more fish?

Well here’s the problem, maybe we have applied the wrong model that does not consider other factors involved with being a human just like the whale guys.

Firstly, human beings are not simply a mechanical system, they are a biological system that displays both variance and adaptability.

This means that one part does not have a simple knock on effect to another. The body DOES display interdependence but also independence and it does this in a very individual way that simple all encompassing models do not really reflect.

  • Humans are adaptable. If we load the body in a variety of dimensions (physical, psychological, social, environmental) it has the ability to get stronger and adapt rather than just wear out like a piece of metal would. How do we know this? Going to the gym and weight training is a great example, or exposing yourself gradually to stimuli such as temperature or a bed of nails.


  • It has redundancy and variability. This simply means the body has a whole bunch of ways of achieving the same task that can reduce repetitive loads that might have a detrimental effect. This is a key defining feature of a biological system.


  • The human body has individual tolerances. Some people can compete in iron men triathlons whilst others struggle to run 5K. Just because you apply a load to a tissue does not mean it will be beyond its tolerance, especially if it has successfully adapted to the load.


We also have to consider the impact on other co existing systems such as the psychological or social.

If you tell a person moving is bad then they may form a belief that moving is bad and stop moving, or perhaps your workplace has specific rules about lifting technique and this influences the way you protect your back. We are very impressionable creatures after all.

Stopping people from flexing their spines is a great example of a simple mechanical view having an effect on the psychosocial perception of movement or activity and a potential detrimental outcome.

If I do not flex my spine due to the belief that this is BAD, its tolerance to moving and flexing might actually DECREASE as it is not being loaded. Astronauts do not load their bodies as much due to decreased gravity. Their bodies and bone mass adapt negatively, a process of atrophy (remember adaptation happens both ways). This can also happen after immobilisation of a limb following a fracture or a sprain, consider the long term effects of complex regional pain syndrome.

So in essence one system, the psychological or social has had an effect on another system - the biological, all of this originating from a mechanical viewpoint. A familiar image of categorical thinking and reductionism is depicted in this image.

Elephant 1



So even though things seem simple and make sense, consider that simple may not always explain the cause.

Be more WHALE and less HUMAN.