Quasimodo is just fine

NOTE: This is mostly a reflection on posture correction. To clarify context, these reflections would change a bit in the pediatric world and with patients with neurological conditions such as poliomyelitis or Guillain–Barré syndrome.

Ever since I became a physical therapist I have learned about ideal posture and how to correct a patient’s posture and alignment. Why?

I have learned with suspicious tests how good posture places muscles and the nervous system in a more optimal position to respond to external forces. I have learned from outdated sources that with the proper posture you will have less pain. But the cherry on top, what frustrated me the most, was when I heard a revered instructor using Quasimodo as an insulting example of poor posture. And that did it! You don’t get to bully my fictional hero and use him as an insult without a written reprisal from me. Poor Quasimodo! even after death has he to endure society’s unapologetic constructs. 

"Health is the ability to be comfortable in your own skin." Nortin M. Hadler, MD.

There are several assumptions made every time I correct someone’s posture. First, I am assuming that the person’s function is decreased because of her or his poor posture. This foundational assumed idea is taught in physical therapy schools as well as in continuing education courses. I believe this was derived from the books written by Florence and Henry Kendall on posture and pain in 1949’s. The Kendalls were pioneers in the early development and refinement of muscle testing. They spent many years treating patients with polio at Children's Hospital in Baltimore. The paradigm was to find a relationship between muscle imbalances and their resultant faulty postures and pain syndromes. 

Second, if the patient is in pain, I am assuming that the pain may be due in part to his or her poor posture. As you will see later, this has been refuted by trials many times.

Finally, and perhaps most importantly, by improving someone's posture I am improving his or her function and therefore I am assuming that I am making that person healthier. I am implicitly making posture a determinant of health. In other words, I am suggesting that a person with good posture is healthier than a person with bad posture? Who I am to tell Quasimodo, or the Olympic medalist in the wheelchair, or the posterior/anterior tap-dancer with an amputation, that they are not well? That they are not healthy? Simply put, this is nonsense. 

Many things have changed since 1949. Pain Neuroscience came along and is more accessible than ever. In addition, hundreds of research studies on posture and muscle function and pain have been published since then. Here are a few of those articles (all systematic reviews. A systematic review is a study that reviews many studies on the same subject):

• This systematic review shows how tight hip flexors or weak abdominals are not associated with anterior pelvic tilt.
• In this systematic review, thoracic kyphosis was not associated with shoulder pain.
• Here, they found no association between an extended low back or flexed upper back and pain.
• This one shows that the glute muscles are not inhibited by anterior pelvic tilt.
• Here, significantly misaligned patellas are perfectly normal.
• This systematic review found no association between neck posture and neck pain. In fact, whether you are happy at work or not (psychosocial factors) has a greater correlation with neck and low back pain than posture. 
• In this systematic review, Quasimodo’s awkward work posture was not associated with low back pain. (It wasn't done on Quasimodo, but he would fit well here).

You can have rheumatoid arthritis and still have your health if you are a person with rheumatoid arthritis and not a “rheumatoid.” Nortin M. Hadler, MD.