[00:00] TB: Hello and welcome to the Pain Podcast. My name is Tim Beams, and I'm joined by Bart van Buchem. We're going to talk today about another myth out there, the myth around posture and pain, and whether or not there is such a thing as bad posture. We've taken great delight actually, already just amusing ourselves with the different pictures and Instagram posts and what have you relating to posture. We can feed a bit of that back in a second, but I'm wondering, Bart, whether many of your patients come to see you and either they've been told or they tell you that they think their pain is posture-related or that they have bad posture?

[00:45] BvB: Yeah, it happens all the time. I think it's so... I think it's definitely an idea that sits in society, at least in Dutch society. I guess it's pretty common. People seem to be quite surprised when it's different. That's my reflection - people are literally shocked by knowing or getting somewhat different information about posture than they thought. I'm always asking, "So where did that information come from? Where did it tell you that this is a bad posture and it's causing your back pain?"

[01:20] TB: And what do they say?

[01:22] BvB: Well, actually, sometimes it happens in childhood. "My mom always taught me." And for others, people said they've always been corrected on posture by, let's say, during their school years. Just the teacher basically requiring "straightforward, shoulders back, chin in." And otherwise, it will be the parents telling you, "You have to... you shouldn't slouch and sit straight." I think that's... it's really... Well, I think it will be very similar to myself as well. I think I've been confronted with some alternative information since I started doing my degrees in physiotherapy, perhaps.

[02:05] TB: Yeah, yeah. I'm wondering... I was just... I thought you were going to tell us about your kids because, you know, having kids is a really good insight into the sorts of positions, postures, etc., that they get themselves into. I'm always quite fascinated with what my kids do, like draping themselves over chairs and... it's like an exploration of all the different potential ways of using a chair.

[02:30] BvB: Oh, exactly. Yeah, I love it. And sometimes, you can't... they will correct themselves in the end. I mean, when they've fallen off in that particular way enough times, it's used less often. Isn't it? When they start... when getting themselves up to the toilet or so, it's "Oh my God, I don't have any feeling in my hands or in my feet. It's tingling, pins and needles."

[02:55] TB: Yeah, yeah, yeah. They will explore. I like the idea of exploring, for sure.

[03:00] BvB: Yeah, yeah, yeah. Totally.

[03:05] TB: Although, and the reason we're doing this podcast is really to have a balanced opinion, isn't it? So I mean, I can see with my children where I want to sort of say, "Oh, come on, just sit up straight" or "Stay in your chair," and I also have this other voice in my head going, "They're kids, let them do what they want to do and move how they want to move." And ultimately, that voice, the alternative voice in my head, is the one that's saying we should have that freedom, shouldn't we? We should have the flexibility and the freedom.

[03:35] BvB: I mean, it's called many different things - motor abundance, variability - to move in many different ways or to adopt a number of different postures. Something again, if I'm sort of reflecting on this question and thinking about my own experiences, what I notice now is I spend a lot of time sat in front of computers, which didn't seem to be on the agenda, on the cards studying physiotherapy originally. I thought I'd be quite an active person, but I have to, for myself, to get up and move. I have to... I have to put that into my day, and it's a very deliberate thing that I make sure I get out of my chair regularly, move myself regularly. I exercise regularly as well because I'm mindful of the amount of inactivity that I have in my day where I'm adopting, in essence, very similar posture for long periods of the day. And I don't feel like, for me, that is a great thing. I noticed when I haven't been able to give myself opportunities to get up and move and sort of break break up that day as well.

[04:45] TB: Yeah, and it also does... it does feel different compared to 10 years ago. I have to say, I'm definitely less resilient to sitting down and not moving. It definitely makes me feel older.

[05:00] BvB: At least I'm standing up. Although it can differ as well. Sometimes you actually can sit for a long time; it doesn't really make any difference. And sometimes, like 10 minutes is like, "I need to move," or otherwise, you will find out... well, once you start moving again. But I think the whole thing is like the freedom to explore and... and also, I think sitting in... inactivity may be in a broader sense is definitely a problem. And I think that's where the nuance lies, right? Where inactivity versus passivity, sorry, positivity or activity versus flexibility. I guess that's where I feel my comfort, where I need to move because I always have done so far. But I do see people who are like world champions sitting. They... they do pretty well sitting down and not having a lot of issues. I'm not sure if they're healthier, but they do seem to do a good job in doing that. So it's really interesting. So whether you're going to get these people sitting or standing up and doing movements during the day, they sometimes get really frustrated and not necessarily feeling better with the advice. So that's where the... that's, so let's say, the physio advice may sit...

[06:15] TB: Yeah, it's interesting. Also, what I also find out when people... when we talk about posture, they start to apologize for themselves. "Yeah, I know I'm... I've got a bad posture" or "I know I'm sitting too much." So... and so why... you're asking, "Why are you saying this?" "Well, you're a physio, right? And you should do... I should do more because that's what physios want." So there seems to be quite a strong, let's say, this... this sticks with our profession, I guess.

[06:45] TB: Yeah, yeah. What you see... you see someone sitting wrong from a... from a mile away. I mean, I wonder whether... so there's a few things that like crop up for me there. Is... is like that self-blame? We've talked about self-blame before, haven't we? And we're brilliant at being our own saboteurs in... in thinking and... and doing and acting and what have you. But... but I'm wondering about whether or not, for instance, there is such a thing as bad or good posture. Or, you know, is it just what it is? Who's... who's to say that it's good posture or who's to say it's bad posture? Is it because it just literally looks more pleasing on the eye? I get...

[07:30] BvB: Well, that's a good... maybe... maybe it is also because it's like... I think we just have to go back... back to... to like back in the ages, right? What has... I'm not sure if the Romans were pretty lazy, especially when they were rich and wealthy. They were lying down in all kinds of positions and not necessarily looking active. It was rather the people who did the work who... who looked like healthier. Although they... they didn't seem to survive those times. But it's... I think it has at some point... it has become like... being... being straight or sitting straight might also tell you something about someone's personality or, let's say, how you feel being confident. I think that's become more and more important to do that. Maybe like the non-verbal... non-verbalized version is sitting straight. And if you don't do that, you look like shit, and you're... you should... you should do better because we don't... as a parent, I don't want to... look... see my child sitting like this because other people would have a... have an opinion on that. And basically telling them the personality or they're not resilient, right? They're not strong. They should look strong. Which is interesting. I guess that's... maybe some of the part.

[08:45] TB: I'm wondering... yeah, I... I'm thinking of like marketing campaigns like "sitting is the new smoking" and things like that. And grabbing the sort of emotional experience of... of... of people to... to help as a catalyst for behavioral change. I went to my... hygienist, dental hygienist, a few weeks back, and he was saying, "Do you floss?" I was like, "Yes, I floss." "How often?" "A couple of times a week." "That's not enough. You've got to do more." And I said to him, "Oh, do you feel like saying that to me is going to help me to do more?" And that sort of got lost in the ether somewhere. I think he'd just been told that he needs to tell everybody to do more. But I didn't feel like... see, it was possible.

[09:30] BvB: I'm... I'm really interested because the... the... the idea of expression through your posture is a really interesting thing. And... and... and something that when you see people in pain, that can change is their ability to be able to express themselves. So you do see a... a shift and a change in the way that they move or the types of postures that they adopt. Their expression of self through their posture as well can change. And that's a really interesting observation of yours and something that you see in a process of recovery is as a sort of a nonverbal cue is often that someone literally is moving like the way that they express... express themselves are just... just a little bit different. And... and it's not surprising if... if when you are in pain, you're not feeling awesome, you don't feel really happy and excited, and that you express that through your posture as well. And that to say that's bad, it is another... there's a real downbeat on... on that person who is already struggling in... in their world.

[10:30] TB: So yeah, I... I'm interest... I'm interested in that. Should we... if that is the case, I mean, we could just as easily emphasize creating a condition of joy and happiness and feeling like, you know, whatever bright would be for that person rather than telling them to sit upright or pull their shoulders back. Or... we... we did lovely search, didn't we? We saw lots of pictures of... of these very healthy people showing you how you should sit and stand.

[11:00] BvB: Yeah, we should... we should... you just mentioned it. I thought like, "Oh hell, yeah, that's going to... that's exactly what's happening," especially on Instagram. But also, the... that so... the images they use for posture are typically young, healthy, good-looking people trying to look like they're having a bad posture and having back pain, which is... it's ironically the people who has the least problem, probably, were asked as a... as an... as an example, which is also makes it less... well, less interesting, I guess, when you... I'm not sure whether these posts are targeted on... on healthcare professionals to start using the stuff where it's on consumers. But I think one of the comments that we get from consumers from research that actually they're using the wrong images and the wrong sentences because we're not... and I'm not... it's not really... it really doesn't look appealing to me like this, which is really important to me as well. As I'm trying to find a different strategy to... to discuss posture because we can say, "Well, it doesn't matter posture," which will be the other end of the... the spectrum. And sometimes for people, there would be too contrary, right? So too... too much of... let's just the opposite. And that can be frustrating.

[12:15] TB: I... I'd rather start exploring postures and what it makes you feel. So some people feel very guilty when they start slouching, which I found... wow, if you... so... so imagine you're slouching right now and feeling guilt, like real guilt. "I shouldn't do this because other..." There's a whole range of reasons like my physio told me, or my doctor, my parents, my school teacher. I guess that's... that's amazing, right? Because then posture has started to create something new. It's not like... this is definitely not what we're looking for in the first place. But if it is, I love it because it... it allows you to explore it and see... can you try it a bit more? And... and even making pictures of people who think they slouch are quite surprised when they see that back in the... what they think is very slouched in the lower back. And it's actually not slouched at all because the pictures show that there's very limited flexion in the lower back. So they're really surprised. It's actually the shoulders that move more in a different direction, which would be... that's really interesting. But... but showing that image actually creates some... in my experience, really creates some... some violation of this expectation.

[13:30] TB: Yeah, and that's where we can gently start exploring. Perhaps there are different movements. Maybe there are many other ways of using your posture to feel different. Or if you feel vulnerable, how to... to cope with that, especially when it comes to back pain. You feel like sitting straight up is very helpful because it gives you that feeling of control.

[13:55] BvB: Yeah, it does feel control, but it's very tiring as well. And maybe... what's your experience like, Tim, with... with posture and... and in the clinical setting?

[14:10] TB: Yeah, so I... I like your ideas there, and perhaps we need to summarize them because they're so... so much. But very often, the people I'm seeing, for instance, I've just got off a call with someone who has pelvic pain, and sitting is a problem. But also standing for periods of time is a problem. So there is some sort of postural link in terms of their pain. So to ignore that would be harmful, I think. Anyway, to be harmful or to say things like... or you know, like you said, the contrary message where you're saying actually posture has nothing to do with it. Well, clearly, it does. Clearly, there is a link that they are struggling sitting, and sitting accounts for a lot of our day, actually. Not... this is not a negative thing. It's just what we do. We sit down for periods. And being and struggling being able to do that actually is massively impacting on your life. So figuring that out with that person, I... is... is a really important part of... of my work with them sometimes.

[15:15] BvB: Yeah, I... I think that would be like a typical... a very common example, that sitting might be a problem. Another thing, but perhaps we don't see it so much, although perhaps we need to do some searches on... on a bed posture or something like that. But... but there are certain positions that people struggle in bed as well, whether it's sleeping on their back or their side or... or whatever it might be.

[15:40] TB: Yeah, so and... yeah. And you get, you know, people are peddling messages about the right... the right pillows, the right mattresses, whether or not you put something between your knees or under your arm, or... or you do whatever you need to do in order for you to get a really good night's rest. And if you're in pain, that might need a bit more consideration. So... so there are ways of just exploring and experimenting so you find a way. But yeah, if... if... if pain and adopting postures is problematic, then it's something that you should spend some time on. But that to... to say that it's because you have bad posture, you know, your posture is wrong, I... I think isn't helpful.

[16:25] BvB: So flipping that around to... to noticing that adopting certain postures and positions can be challenging

[16:35] TB: I think is important. And widening the possibilities, bringing more possibilities in, I think can be really helpful as well. So whether that's... whether that's, you know, finding... and then I'm thinking about some of the men that I work with with pelvic pain. It might be that they can sit on a comfortable chair or with one of those... those circular donut cushions or... or... or whatever to begin with. But just create the condition that they might be able to sit, even though it's not for as long as they want, is... is really key. So maintaining the ability instead of shutting it off and... and... and having none of that in your life, finding alternative ways of... of bringing that in, I think is important.

[17:20] BvB: Yeah, and it's not like getting... you don't have to blame it, right? So you don't have to refute the... the idea of that posture can be influential because that's... it can be a factor. But it may be more complicated than... than you think because when... especially it's like breathing, right? You don't... you're not... you don't mention that actually breathing is... you never mentioned so breathing is very normal, but it may change. It may vary due to conditions, and I think posture does exactly the same. It can tell you something about fatigue. It can tell you something about personality. It can be something about feeling safe or unsafe. And by blaming that, say it's bad, it's just like you said, I think it's bad. It's a... no, it's a nocebo to do it because it's not necessarily something... I... I do think it's something... a reason because when it... there is a reason to mention it or to discuss it or to not necessarily confront, but at least show it to people what's going on and allow them to mirror it and to see what's going on. Because you never... it's an opportunity for treatment rather than creating that... that... that good or right or wrong idea, which is... I think it's very harmful as well.

[18:40] TB: And when it's bad, and I think that's the whole thing in... in social media but also in... in... in YouTube and other channels and websites, that when it's bad, just click through. You will find out they have a... they usually have a device to correct it. They're not asking you how you feel about it. They will have something to sell. So actually, they say there's something wrong with you, and here is the solution, which is great marketing from that perspective, but...

[19:10] BvB: It's very unlikely that it will be the solution. I think it's better to explore it and see if this device can be helpful. I do think some devices like having a cushion or whatsoever can be helpful, some... some in some cases. But like the... the let's say the... the help or the... the ever solution for everything, that's... that's definitely not going to be it. People are... my patients do have tried every single device you can imagine.

[19:40] TB: Everything, yeah.

BvB: And no one... they will always tell you like, "Nothing helped," and they tend to be very like hopeful in the beginning because of the messaging or the... the marketing basically was like very... making for them... making them... it sounded like reasonable and valid to them, plausible. And then they start using it, and they... and they start feeling like, "All right, it's actually... this is working." And then after a while, probably days, maybe even hours, they would realize that, "Well, actually, not... it's not what I thought it would be." So... again, like that... that's where... where we should be considering to be more careful about what posture basically means. It's about so much more than just anatomy.

[20:25] TB: Yeah, yeah, yeah. And... and as you're saying that, and first of all, I'm just... agreed that there are times and... and situations where certain devices are really, really helpful. I mean, I remember... remember the lumbar roll was a big thing certainly in the late 90s, early 2000s. And I hate to think how much our department at that point, when I... where I was working, how it spent on... on things like that. But, you know, rolling up a towel and putting in the... in the back was... was a really lovely thing for some people with back pain and... and so easy as a solution.

[21:00] BvB: But I'm just coming back to, you know, if it's a... if they've got back pain, is a fairly new onset or maybe it's been grumbling away for... for a year or two years, their posture probably served them really well before that. But it just so happens that there's a different flavor when you're in pain in terms of... of how you feel and what you move like and... and how you express yourself. And yeah, I... and... and so I... there... there is that like the pain-specific shift that... that we would get.

[21:30] TB: I... I was... sorry, my scattergun brain is just coming... self-blame obviously coming in here, but I was thinking there's not... everybody can do this. So obviously, depending on where you work, you might not be able to do this, but taking a picture or a video of someone, you know, or be it on their phone and showing them back can be transformational, can't it? Like someone... "Do I really sit like... do I really move like that?" or "Oh, not so bad after all." And... and there are studies on body perceptual change and things, aren't there, relating to low back pain and how people identify, you know, what they... what they feel like isn't necessarily where they are. And that disconnect between the perceptual processes and the... and the sensory data that's coming aren't... they don't equate, they're not... they're not matching up. So we are in a wonderful place in order for us to be able to help shift that back and... and using very simple strategies and tools like some visual feedback from camera or mirror or the feel of someone's hands as you're doing it can be just awesome, can't they?

[22:40] BvB: It is. It's very powerful, as well as the nocebo effect of using the words as bad. And I just want to highlight that we're going to have a... a session, a science session with Andrea Evers. She's a professor at Leiden University. She's going to talk about nocebo and placebo effects... regards words, use of words as a... as a scientist. And she's... she's like a heavyweight in the world of placebo and nocebo research. She's done amazing stuff. So go check her out. She... she's... she will be our guest at the 3rd of July. So that will be something that will be announced shortly. Something just to... to hang in there, and... we'll have some discussion around that. So that will be... I'm really looking forward to that session.

[23:25] TB: So... so now I feel like we need to give some placebo language or some positive language. And if you've got any specific phrases that you use, the first one that comes to mind, and I occasionally use it, is "your next position is your best position." Have you got any that go-to sort of ways that you might explain something posturally to someone?

[23:50] BvB: Yeah, I like the experiment with the picture, for example, which I really, really enjoy because that's something like a process. It's not just that word. It's basically the proof and that experience. What does it make you feel like? Adding the emotional component and... and asking people to... to run an experiment over the next week. Just try to... you think... just touch your... the back, the back of your seat if you sit down. Just make sure you... you touch the back of your seat and see what's happening. And people find out actually they're sitting... they're sitting always on the... on the... on the front of the seat, right? So they're really in a sort of a... how do you say that... like very aroused... they're sitting there, and... and therefore, they... they're very much on it. And that they didn't realize it. So and after a week, they found out like, "Wow, what happening? I'm amazed how that worked out." And it was so easy just to not... just... just using that back of the seat, which was actually quite comfortable.

[24:50] TB: As well as... experiments running it with like putting pressure on people instead of sitting straight up and just slouch it and see how much you can handle with the same somewhat the same... same weight on your shoulders and see how that goes. So this experiment will very likely be very beneficial to people who's starting to explore somewhat more flexion in the back because that's anatomically... it's... it's like a good thing to do. Or at this is a sensible thing to do, and it actually makes you feel carrying less. So people experience being less hyperventilated. They're actually more comfortable with... with bearing weight. And that's like... that's mind-blowing for some people. And I'm... I'm always looking for that... that bit, that... that little... that little experience because that's what would take people... they will take it home, right? This is what makes... makes you like, "Wow, this is something I need to repeat" instead of just the words. I think it's the combination.

[25:45] TB: Yeah, yeah, yeah. The experiential process, absolutely. Yeah, yeah.

BvB: So, well, I guess we have to sum up, unfortunately. But that's been... it's been great having a chat.

[26:00] TB: And... well, we... we came here thinking about whether posture... whether there was such a thing as bad posture and the relationship of posture and pain. And... and what we've basically covered is that when someone's in pain, it can... it can absolutely have an effect on their posture. And... and that may be that they struggle to get into certain postures, different sitting postures, standing, lying, whatever it might be. It might be through the expression physically of themselves, and... and maybe there is a relationship. I'm always thinking about the basal ganglia in emotion. So... so yeah, you see a difference in the expression and the like the physicality of someone and how they... express themselves through their body.

[26:40] BvB: Perhaps there's a few nocebo messages out there. But oh wow, I mean, if we really look at it, we've got our... we can blame our parents for everything, can't we? And I'm sure our children will at some point.

[26:55] TB: But... but... but it's a... it's a wonderful window into what the messaging might be that people are exposed to. So you... you may have been told to sit up, sit straight, sit still, etc., at school, at home, and... and that obviously has influences on you later on in life. And... and then we are bombarded by messages in our world, aren't we, at the moment? And some of the messages that we found very, very easily doing a couple of searches was... that there was... eight signs for bad posture, 10 signs... 10 exercises to sit up straight, and... and all of those sorts of messages. But interestingly, those messages were often delivered by extremely healthy-looking people. And whether or not that was diverse enough or... or... or covered enough of the population who might be struggling with pain and in certain postural positions is... is another matter.

[27:45] BvB: And then we've... discussed some of the more positive ways of... of identifying and using and exploring posture and... and that disconnect, but also of... of giving someone... I'm thinking about the self-efficacy, but giving someone the power to be able to explore and experiment and... and be confident to do that themselves and bring back that concept of motor abundance and... and movement variability.

[28:10] TB: Yes, and just to... to add... the paper that I mentioned... if you want to just write it down if you want, is called "Determinants of behavior and their efficacy as targets of behavioral change interventions." First author is Ali. I'm not sure if I'm... off... but that was in... it's a Nature Review Psychology. So... it's very interesting. I think just one of those things you think how much knowledge contributes to behavior change compared, for example, to emotions is much more. And habit was like a massive, massive contributor on individual factors in... in people what driving change. So something we just have to take into account when we're trying to discuss posture that is... is not just about telling it's bad. We'd rather don't say that. You want to... because I do think when hitting that nocebo, you will get people in trouble. You would... is less likely to get people on board, even if you feel like they could do better.

[29:10] TB: I guess that we shouldn't say that, and... there's no reason to because there's so many other things we can say how much more worthwhile and helpful.

BvB: Yeah, I totally agree with you.

[29:25] TB: So if you've enjoyed the podcast... well, first of all, thanks for listening, and... you made it... you made it to the end. You made it to the end. Get... go out, tell everybody, run down the street and tell them that you've just listened to this amazing podcast and knock on your neighbors' doors. And yes, like, subscribe, share at work, subscribe, etc. If you want to get confident treating pain, then come over to lovephysiotherapy.com, and there's lots available at the moment. There's some free guides. There's a new free guide coming out very, very soon. And... for those premium members, they get access to Andrea Evers' session, for instance, on nocebo language on... 3rd of July. Just save the date, 3rd of July. And... yeah, what better way to... to... to get comfortable... working and happy and enjoy what you're doing because we truly believe you can make a difference. So come on over, check it out, and... wishing everybody all the best. Thank you for listening, and... catch up in another couple weeks again. Ciao!

[30:30] [End of podcast]