In the latest issue of The Journal of Orthopedic and Sports Physical
Therapy Shirley Sahrmann PT, PhD, FAPTA (Professor of physical therapy,
cell biology and physiology, associate professor of neurology; director of
program in movement science, Washington University, St Louis MO)
contributed a provocative guest editorial entitled “Does Postural
Assessment Contribute to Patient Care?”
Dr. Sahrmann advocates postural assessment as a prerequisite for care and
makes a case for this despite an absence of evidence. I think this is an
important issue and have included a number of quotes from the editorial
along with my own thoughts. I’m hoping it will generate some comments from
our community.
Sahrmann begins: “Is the examination of posture just a tradition of
physical therapy practice or is the information gathered from this
assessment useful for diagnosis and treatment?
Dorko- I think it’s an example of the power of tradition and that this is
the primary reason for its persistence.
Sahrmann: “What is the evidence that postural impairments contribute to
pain problems and need to be included in therapists’ examinations? The
simple answer to that question is that there is very little research to
support a relationship between musculoskeletal pain and “posture”. Many
respected texts and articles by physicians, physical therapists, and
physical educators have cited the importance of good postural alignment to
health, but clinical studies have not supported these beliefs. Though I am
fully aware of the lack of evidence, I cannot imagine treating any patient
without assessing posture or, more precisely, alignment…Studies of posture
have focused on a narrow definition. Posture or carriage of the body should
be considered differently than the alignment of one segment in relation to
an immediately adjacent segment.”
Dorko- I treat patients without doing a postural assessment all the time so
imagining it is not necessary for me. Without any evidence for a connection
between postural alignment and health I can’t see any reason to “believe”
in it. Shifting the focus from an overall or regional impression of posture
to a description of segmental alignment seems to be Dr. Sahrmann’s response
to an absence of evidence for the traditional view.
As Dr. Sahrmann continues: “Probably more important than overall posture in
the sagittal plane is the relative alignment of one or two segments in
multiple planes. For example the degree of lumbar curvature can vary a
great deal, but one vertebra cannot change its sagittal position with
another vertebra by more than a couple of millimeters before contributing
to pain from spondylolisthesis.”
Dorko- I’m not aware that the system this sensitive. I don’t think it is.
Sahrmann goes on: “Studies have not addressed whether some postures are
more likely to result in intersegmental changes such as spondylolisthesis
than other postures…Defining subgroups of extreme postures is a necessary
step in the consideration of alignment as a contributor to mechanical pain
problems…Alignment is only one of multiple factors contributing to the
development of mechanical pain…The individual who is overweight with a
ponderous abdomen who stands all day may be at greater risk of developing
back pain than an individual who is slender with the same alignment who
also stands for prolonged periods. I believe most clinicians who use
postural alignment as a guide to their diagnosis and treatment have
consciously or subconsciously defined for themselves the degree of
deviation, the context, and the modifiers that when combined reach a level
of perceived clinical significance.” And “Studies suggesting that posture
was not correlated to muscle strength also raised doubts about the value of
alignment impairments because of the lack of valid information about muscle
function.”
Dorko- No doubt. There is no evidence that correcting postural deviation
leads to pain relief in the research literature or that these deviations
lead to pain in the first place. Still, Dr Sahrmann concludes, “In my
judgment, the current preponderance of negative studies about the
relationship between posture and pain are more reflective of the types of
questions that have been asked and the analysis that has been used than of
the lack of a relationship. Assessment of alignment impairments has to be
an important step in designing an appropriate treatment program for
correcting mechanical impairment. We need to pursue the studies that will
enable us to define the relationships among specific alignment impairments,
altered movement patterns, contributing muscle adaptations, patient
modifiers and mechanical pain problems.”
Dorko- It seems to me that this effort to come up with research to justify
traditional practices is uncalled for, not that anybody has asked my opinion.
I’m wondering what the list thinks.
Barrett L. Dorko, P.T.
<http://barrettdorko.com>
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