The Postural Syndrome


I would define the postural syndrome as mechanical deformation of postural origin causing pain of a strictly intermittent nature, which appears when the soft tissues surrounding the lumbar segments are placed under prolonged stress. This occurs when a person performs activities which keep the lumbar spine in a relatively static position (as in vacuuming, gardening) or when they maintain end positions for any length of time (as in prolonged sitting).


Patients with postural pain are usually aged thirty or under. Frequently they have a sedentary occupation and in general they lack physical fitness. In addition to low back pain they often describe pains in the mid-thoracic and cervical areas. They state that the pain is produced by positions and not by movement, is intermittent and may sometimes disappear for two to three days at a time. It is often found that, when patients are more active at weekends — playing tennis and dancing — they have relatively little or no trouble. The reason is that, although activity places more stress on the lumbar spine than does the adoption of static postures, with movement the stresses are continually changing and pain does not occur. The stresses arising from static postures, although less than those occuring during activity, are sustained and will, if maintained, eventually cause pain.

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On examination no deformity is evident, no loss of movement will be detected and the test movements prove to be painfree. X-rays are normal and laboratory tests are negative. The patient’s sitting and often the standing posture will be poor, and usually this is the only objective finding.

Clinical example

Let us look at the clinical example of a typical patient with the postural syndrome. The patient has a bad posture indeed, and the pain cannot be reproduced by the test movements. To reproduce the appropriate postural stress, the patient must assume and maintain the position that is stated to cause pain — that is, the sitting posture. Only after the passage of sufficient time will the symptoms appear in this position, and up to half an hour may be required before pain is felt. Once pain has been produced by adoption of a certain posture, it will be abolished by correction of that posture. Now our suspicions are confirmed and a diagnosis can be made. In short, the patient with the postural syndrome has no clinical or laboratory findings indicating a particular pathology and all functions appear perfectly normal.

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Thousands of people are seeking treatment for pain resulting from bad postures; they consult doctors who often are unsuited to deal with the problem and, taking the easiest way out, prescribe pain relieving drugs instead of recommending postural correction; disillusioned with drug therapy patients attend a chiropractor, osteopath, physiotherapist or some fringe manipulator who, mainly out of ignorance, proceeds to manipulate joints in which there is no pathology and certainly nothing ‘out of place’.

I must emphasise that in many patients presenting with postural pain no pathology needs to exist. All patients with low back pain have an increase in pain when postural stresses are added. In derangement and dysfunction there is a pathological cause for the pain, and postural stresses may enhance the pathological state. But in the postural syndrome no pathology is present, and the only treatment that is required is postural correction and re-education and instruction in prophylaxis.

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Postures involved

Every patient with pain of postural origin has a different description for the circumstances leading to the production of pain. Sitting, by no means the only postural situation causing and prolonging low back pain, is the most frequent cause of postural pain. Some patients will name the sitting position purely and simply as causative, and they complain that pain is produced as soon as they spend more than a certain amount of time, say ten minutes, in any sort of chair or car seat. Others will describe sitting at the typewriter as the only time that pain is felt. Bus, taxi, and car drivers all complain of being worse while seated for long periods in their vehicles; both pilots and passengers complain about the seating in airplanes.


Fig. Clinical example of a typical patient with the postural syndrome.

Fig. Sitting postures.

Working in prolonged standing positions also may cause postural pain, but the opportunity to move and change position is greater in standing than in sitting and the avenues for relief are more numerous. Consequently, there are less complaints of pain arising from the standing position than from sitting. People who work in cramped positions, be it standing or sitting, are also likely to complain of low back pain. The incidence of low back pain is very high in people who work in continuously stooped positions.

Fig. Standing postures.

The lying position may be an additional source of stress enhancing low back pain, and if pain predominantly occurs while lying it requires thorough investigation.


Fig. Lying posture.

TYPICAL TREATMENT PROGRESSION — THE POSTURAL SYNDROME The days referred to in the treatment progression are related to treatment sessions which do not necessarily take place on consecutive days. This also applies for the treatment progressions of the dysfunction and derangement syndromes. Day one Assessment and conclusion/diagnosis. Postural discussion ensuring adequate explanation of the nature of the problem. The patient must understand the cause of pain. I usually give the simple example of pain arising from the passively bent forefinger. We must satisfy ourselves and the patient that the pain can be induced and abolished by positioning. If it is not possible to induce pain during the first treatment session, the patient must be instructed mow to abolish pain by postural correction when next it appears. Commence with postural correction exercises and give postural advice; do not try to teach too much the first visit. Discuss the importance of maintenance of the lordosis while sitting prolonged, and demonstrate the u...
Spine Health. PROCEDURE 11 — SUSTAINED ROTATION/MOBILISATION IN FLEXION The patient lies supine on the couch, and the therapist stands on the side to which the legs are to be drawn, facing the head end of the couch. The patient’s far shoulder is held firmly on the couch by the therapist’s near hand, providing fixation and stabilisation. With the other hand the therapist flexes the patient’s hips and knees to a rightangle and carries them towards himself, causing the lumbar spine to rotate. With the patient’s ankles resting on the therapist’s thigh the knees are allowed to sink as far as possible and the legs are permitted to rest in that extreme position. The lumbar spine is now hanging on its ligaments in a position which combines side bending and rotation. By pushing the knees further towards the floor the therapist applies overpressure to take up the remaining slack in the lumbar spine. Depending on the purpose for which the procedure is used, the position of extreme rotation is maintained for a shorter or longer period. Fig. Sustained rotation/mob...
Spine Health. PROCEDURE 3 — EXTENSION IN LYING The patient, already lying prone, places the hands (palms down) near the shoulders as for the traditional press-up exercise. He now presses the top half of his body up by straightening the arms, while the bottom half, from the pelvis down is allowed to sag with gravity. The top half of the body is then lowered and the exercise is repeated about ten times. The first two or three movements should be carried out with some caution, but once these are found to be safe the remaining extension stresses may become successively stronger until the last movement is made to the maximum possible extension range. If the first series of exercises appears beneficial, then a second series may be indicated. More vigour can be applied and a better effect will be obtained if the last two or three extension stresses are sustained for a few seconds. It is essential to obtain the maximum elevation by the tenth excursion and once obtained the lumbar spine should be permitted to relax into the most extreme ...
TREATMENT OF THE POSTURAL SYNDROME Every patient must be examined and analysed individually, and educated for his own particular postural stress. Education is probably the most important part of the treatment for low back pain of postural origin. The patient must have a clear and unambiguous explanation of the mechanism that produces his pain. He must realise that, when he assumes the positions of stress causing pain, he is in fact pulling the ligaments apart; and all that is required to stop his postural pain, is to stop stressing the ligaments for about ten days. I also explain to the patient that once he commences the correction regime, he will and should develop some new pains which are commonly felt higher in the back. This is merely the consequence of adjustment to a new postural habit. The more often pain is triggered, the more readily it will occur. And the less often pain is triggered, the more difficult it is to be produced. Thus, poor sitting positions maintained regularly will cause pain after the passage...
Spine Health. PROCEDURE 16 — CORRECTION OF LATERAL SHIFT This procedure has two parts: first the deformity in scoliosis is corrected; then, if present, the deformity in kyphosis is reduced and full extension is restored. The patient, standing with the feet about thirty centimeters apart, is asked to clearly define the areas where pain is being felt at present. The therapist stands on the side to which the patient is deviating and places the patient’s near elbow at a right angle by his side. The elbow will be used to increase the lateral pressure against the patient’s rib cage. The therapist’s arms encircle the patient’s trunk, clasping the hands about the rim of the pelvis. Now the therapist presses his shoulder against the patient’s elbow, pushing the patient’s rib cage, thoracic and upper lumbar spine away while at the same time drawing the patient’s pelvis towards himself. In this manner the deformity in scoliosis is reduced and, if possible slightly overcorrected. Initially, there will be significant resistance to the procedure, wh...