Barrett:

Thank you for starting this discussion. Please see below.


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?

White: Posture needs to be defined and put into the clinical context. Static
posture, dynamic posture are two very different things. To look at a pt.
with cervical pain sitting on a plinth and attribute the forward head
finding to the cervical pain is not very effective in my experience. Or to
have a pt. stand and look at static posture for LBP is also not very
helpful. The pt. may only be in the static posture for seconds or minutes in
a day. Hardly long enough for is to be symptomatic unless there are extreme
deviations.

A 30 degree genu valgum is a significant finding and one that may need
surgical attention. As a PT I won't correct that impairment but it does help
me make a diagnosis.

The human body is capable of great adaptation. I have yet to see someone who
fits the definition of "normal." It is more likely that faulty posture
associated with prolonged activities is causative of subsequent tissue
injury and pain than what can be observed in a static snapshot examination.

PTs very often look to the periphery when attempting to treat a painful
area. The old foot orthotics for cervical pain approach. I believe posture
is most likely to be temporally causal when it is proximal to the
symptomatic area.

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."

White: Not only is there a lack of evidence as Sahrmann states above but
there is ample evidence tot he contrary. Studies that demonstrate disc
herniations, spondylothesis, and all kinds of spinal abnormalities in
asymptomatic people show that not only is posture not necessarily causative
of symptoms but major mechanical impairments do not necessarily cause pain.

Scoliosis is probable the best argument against the static posture
assessment as being causal to spinal pain. Given the large deviations found
in individuals in scoliosis and that most of them are asymptomatic argues
against a forward head or "flat back" as being symptomatic.

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."

White: Sahrmann's comment on saggital motion and spondylothesis is tenuous.
It is the chicken and the egg paradox. Which came first the sagital
translation or the spondylothesis. Does the hyperlordosis of female gymnasts
predispose spondylothesis or is it the forces applied to the spine from the
sport or both? Is there another reason? How many gymnasts have asymptomatic
spondylothesis prior to starting their sport and the high demands of the
sport causes the pain and subsequent diagnosis. It would be interesting to
do a study of female adolescents gymnasts and a control. X-ray them all and
see the prevalence of spondylothesis.


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.

White: I agree with Sharmann on this point. It is extreme postures
particularly associated with activity that are our best bet in linking
posture to pain.

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.

White: While intuitively this sounds reasonable. It is not representative of
my patient population over the decades.

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."

White: From my understanding of Sharman's philosophy over the years the
above seems to be a major shift in her dogma.

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."

White: Sharman seems to be advocating what many other PTs advocate. Lets
design a study(s) that demonstrate that what I do works. As opposed to
looking at specific conditions and attempting to find answers to etiology,
and what interventions are the most efficacious, safest and cost effective.

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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Douglas M. White, PT, OCS
191 Blue Hills Parkway
Milton, MA USA 02186
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