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>