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.


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.


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.

Spine Health. PROCEDURE 15 — FLEXION IN STEP STANDING In this procedure the patient stands on one leg while the other leg rests with the foot on a stool so that hip and knee are about ninety degrees flexed. Keeping the weight bearing leg straight the patient draws himself into a flexed position, firmly approximating the shoulder and the already raised knee (both being on the same side). If possible the shoulder should be moved even lower than the knee. The patient may apply further pressure by pulling on the ankle of the raised foot. The pressure is then released and the patient returns to the upright position. The sequence is repeated about six to ten times. It is important that the patient returns to neutral standing and restores the lordosis in between each movement. Fig. Flexion in step standing. Effects: This procedure causes an asymmetrical flexion stress on the affected segments. It is applied when there is a deviation in flexion, which may occur in dysfunction as well as derangement. Both in dysfunction and derangement th...
Spine Health. PROCEDURE 12 — ROTATION MANIPULATION IN FLEXION The sequence of procedure 11 must be followed completely to perform the required pre-manipulative testing. If the manipulation is indicated a sudden thrust of high velocity and small amplitude is performed, moving the spine into extreme side bending and rotation. Fig. Rotation manipulation in flexion. Effects: There are many techniques devised for rotation manipulation of the lumbar spine. When rotation of the lumbar spine is achieved by using the legs of the patient as a lever or fulcrum of movement, confusion arises as to the direction in which the lumbar spine rotates. This is judged by the movement of the upper vertebrae in relation to the lower — for example, if the patient is lying supine and the legs are taken to the right, then the lumbar spine rotates to the left. It has become widely accepted that rotation manipulation of the spine should be performed by rotation away from the painful side. This has applied to derangement as well as dysfunction, because hitherto n...
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 ...
Back pain. The Cause of Pain THE NOCICEPTIVE RECEPTOR SYSTEM Most tissues in the body possess a system of nerve endings which, being particularly sensitive to tissue dysfunction, may be referred to as nociceptive receptors. The free nerve endings of the nociceptive system provide the means by which we are made aware of pain. Wyke describes the distribution of the nociceptive receptor system in the lumbar area: it is found in the skin and subcutaneous tissue; throughout the fibrous capsule of all the synovial apophyseal joints and sacro-iliac joints; in the longitudinal ligaments, the fiaval and interspinous ligaments and sacro-iliac ligaments; in the periosteum covering the vertebral bodies and arches, and in the fascia, aponeuroses and tendons attached thereto; and also in the spinal dura mater, including the dural sleeves surrounding the nerve roots. The nociceptive innervation of the spinal ligaments varies from one ligament to another. The system is found to be most dense in the posterior longitudinal l...
Spine Health. PROCEDURE 14 — FLEXION IN STANDING The simple toe touching exercise in standing does not need much elaboration. The patient, standing with the feet about thirty centimeters apart, bends forward sliding the hands down the front of the legs in order to have some support and to measure the degree of flexion achieved. On reaching the maximum flexion allowed by pain or range, the patient returns to the upright position. The sequence is repeated about ten times, should be performed rhythmically, and initially with caution and without vigour. It is important to ensure that in between each movement the patient returns to neutral standing. Fig. Flexion in standing. Effects: Flexion in standing differs from flexion in lying in various ways. Naturally, the gravitational and compressive forces act differently in both situations. In flexion in standing the movement takes place from above downwards, and the lower lumbar and lumbo-sacral joints are placed on full stretch only at the end of the movement. In addition, the lumbo...