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.

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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.

Back Pain History Taking an accurate history is the most important part of the initial consultation when one is dealing with any medical or surgical problem. Unfortunately, when the mechanical lesion is involved there is still lack of understanding regarding the nature of the questions that should be asked, the reasons for asking them, and the conclusions to be drawn from the answers. I will set out step by step the stages that should be developed in history taking, and the questions that should be asked at each stage. Practitioners will already have their own method of history taking, and I do not suggest at all that they should alter their routine. However, I believe that the following questions must be included, if one is to reach a conclusion following the examination of patients with mechanical low back pain. INTERROGATION As well as the usual questions regarding name, age and address, one should enquire as to the occupation of the patient, in particular his position at work which provides us ...
Spinal manipulation techniques There are many differing philosophies and concepts surrounding the practise of spinal manipulation and its effects on the pathologies which may exist in the spine. To satisfy all these philosophies an equal number of institutions has developed, teaching those wishing to learn. No matter what school presents its case or which philosophy is adhered to, all manipulative specialists claim to have a high success rate. They all use techniques which vary in nature, application and intent; they proclaim that their own methods are superior to those used by others; and yet, somehow they all obtain uniformly good results. Self-limitation of low back pain plays, of course, a significant role in this happy situation. Apart from this there are definite benefits which are obtained quickly by using manipulative techniques. Throughout the years I have practised many forms of mobilisation and manipulation, including osteopathic and chiropractic techniques and those taught by Cyriax. I have come to be...
Spine Health. PROCEDURE 7 — EXTENSION MOBILISATION The patient lies prone as for procedure 1. The therapist stands to one side of the patient, crosses the arms and places the heels of the hands on the transverse processes of the appropriate lumbar segment. A gentle pressure is applied symmetrically and immediately released, but the hands must not lose contact. This is repeated rhythmically to the same segment about ten times. Each pressure is a little stronger than the previous one, depending on the patient’s tolerance and the behaviour of the pain. The procedure should be applied to the adjacent segments, one at a time, until all the areas affected have been mobilised. Fig. Positioning of hands prior to extension mobilisation. Extension mobilisation. Effects: In this procedure the external force applied by the therapist enhances the effects on derangement and dysfunction as described for the previous extension procedures. In general, symmetrical pressures are used on patients with central and bilateral symptoms. Therapist-...
Spine Health. PROCEDURE 6 — EXTENSION IN STANDING The patient stands with the feet well apart and places the hands (fingers pointing backwards) in the small of the back across the belt line. He leans backwards as far as possible, using the hands as a fulcrum, and then returns to neutral standing. The exercise is repeated about ten times. As with extension in lying it is necessary to move to the very maximum to obtain the desired result. Fig. Extension in standing. Effects: Extension in standing produces similar effects on derangement and dysfunction as extension in lying, but it is less effective in the earlier treatment stages of both syndromes. Whenever extension in lying is prevented by circumstances, an extension stress can be given by extension in standing. In derangement, extension in standing is designed to reduce accumulation of nuclear material in the posterior compartment of the intervertebral joint, provided this accumulation is not gross. In the latter case extension in lying will have to be performed first. Th...
Spine Health. PROCEDURE 8 — EXTENSION MANIPULATION There are many techniques devised for manipulation of the lumbar spine in extension. It is not important which technique is used, provided the technique is performed on the properly selected patient and applied in the correct direction. The technique that I recommend is similar to the first two manipulations described by Cyriax for the reduction of a lumbar disc lesion. The patient lies prone as for procedure 1. The therapist stands to one side of the patient and, having selected the affected segment, places the hands on either side of the spine as for the technique of extension mobilisation (procedure 7), which is always applied as a premanipulative testing procedure. If following testing the manipulation is indicated, the therapist leans over the patient with the arms at right angles to the spine and forces slowly downwards until the spine feels taut. Then a high velocity thrust of very short amplitude is applied and immediately released. Fig. Extension manipulation. The eff...