The Future of Posture Correction: A Subspecialty of Evidence-Based Medicine.
Within the last 12-15 years, posture correction has drawn more and more attention from both traditional and alternative practitioners alike. As more research is uncovered that illustrates the health risks of poor posture, more interdisciplinary emphasis will be placed on posture correction. Most practitioners who perform posture correction have typically been doctors of chiropractic and physical therapists. Doctors of chiropractic who practice posture correction are coming to a fork in the road. If posture correction remains associated with traditional or “straight” chiropractic, then it may become a fad no different than bellbottom pants. Chiropractic uses spinal manipulation as a primary, if not sole, treatment modality. However, the literature supporting its efficacy is scant beyond acute low back pain and some types of headaches. Despite this, many “straight” chiropractors “educate” their patients on the infinite benefits of regular lifetime spinal manipulation. Chiropractic is largely based upon patient testimonials and unscientific claims about the mythological concept of vertebral subluxation. In contrast, poor posture has been linked to many health problems, from common musculoskeletal pain to pelvic organ prolapse, decreased respiratory function, and decreased GI motility.1-3
Currently, other groups within the chiropractic profession are aggressively differentiating themselves from traditional chiropractic. In fact, a new refereed journal has been recently introduced, the “Journal of Chiropractic Medicine.” This journal advocates the concepts of “chiropractic medicine” and “chiropractic physician” to promote more competent and comprehensive practitioners.4 Some are also promoting the idea of the “Advanced DC” with a degree in chiropractic medicine, or DCM, instead of DC.5 Why are they doing this? Quite simply, the underlying concepts of traditional chiropractic are unfounded. An elementary knowledge of the human vertebral column is enough to deduce that individual vertebrae cannot misalign independently. In fact, this theory has previously been disproven.6 Furthermore, traditional chiropractors often ridicule accepted public health practices, such as immunization.7 This sort of unscientific belief system is a threat to public health when a healing art such as chiropractic, utilized by 10-20% of the population, is based upon a belief system. This is the antithesis of posture correction. With all of this in mind, doctors of chiropractic who practice posture correction will have to decide where exactly their type of care fits into health care delivery.
As mentioned earlier, chiropractic has typically included spinal manipulation or adjusting as a primary treatment method. Many more traditional or “straight” chiropractors view ancillary procedures like rehabilitation, nutrition, ergonomic training, acupuncture, or massage therapy as something separate from chiropractic. Some even convey the attitude that chiropractic is somehow above these other alternative forms of medicine.8 However, a brief review of the literature will show that spinal manipulation is only as effective as massage therapy at restoring joint motion.9 Spinal manipulation has shown little, if any, effectiveness when treating visceral symptoms and disorders.10 In fact, most chiropractic physicians who claim to treat non-musculoskeletal complaints more commonly report the use of treatment modalities other than spinal manipulation.11 Traditional chiropractors claim to detect and correct subluxations only. Unfortunately, there is no evidence available to support the existence of spinal subluxations, or that they have any relation to health or disease.10 Posture correction is a concept derived from procedures and concepts supported by published literature. Problems associated with abnormal posture12,14 have been reported numerous times in the medical literature.13-15 With this in mind, posture correction departs from the more traditional or “straight” view of chiropractic practice. Posture correction is more suited to be associated with those progressive physicians who advocate evidence-based practice and medicine.
In addition to the evidence supporting posture correction and its effects on certain health problems, some of the procedures used in posture correction are not recognized by “straight” chiropractors. These include different forms of traction, long-lever manipulation, mechanical adjusting equipment, and active rehabilitation equipment including head and body weighting, wobble chairs, Dakota traction units, and Regainer units. The combined use of spinal manipulation and some of these rehabilitation procedures has previously shown superiority over spinal manipulation alone.16-18 Because “straight” chiropractic is not evidence-based, perhaps it is wise to begin to strongly consider the long-term consequences of keeping posture correction in the chiropractic realm.
As chiropractic becomes more popular, the clamoring for more research on efficacy and purpose will continue to grow. The importance of evidence-based practice cannot be overstated. Chiropractic procedures based upon hearsay and anecdotes are potentially dangerous to public health. Further, the publication of research allows for the incorporation of many different areas of expertise, greatly increasing the potential for technological and procedural advancement. Again, those who practice posture correction should begin to contemplate the value of associating with individuals who practice “straight” chiropractic based upon outdated theories and unfounded, dualistic “philosophical” concepts.
For posture correction to be identified as a subspecialty of evidence-based medicine, it is important to understand the education needed to properly administer its procedures. First of all, a complete understanding of biomechanics, particularly of the spine and all of its associated structures, is absolutely mandatory. Second, it is imperative to know the neurophysiology of postural control along with the pathoneurophysiology of postural disorders. Finally, the combined application of both manipulative, or adjustive, techniques and rehabilitative procedures is vital to achieve correction of the spine and all tissues associated with it. Presently, some of the accredited chiropractic colleges teach little or no physical rehabilitation in the main curriculum.19 There is also a profound lack of training on the importance of posture and identification of postural disorders.20 In fact, spinal structural deviations are among the radiographic findings most commonly missed by chiropractic students.21 The survey biomechanics courses taught in many chiropractic colleges are also not adequate to learn the complexities of spinal function and dysfunction. Therefore, new chiropractic graduates are not educated enough to competently perform posture correction in the clinical setting. However, there are two different postgraduate certifications in posture correction in which physicians of all disciplines may participate.
Posture correction is based upon the most current literature available. Headaches, spinal pain, scoliosis, trigeminal neuralgia, disc problems, and TMJ Syndrome may all be related to abnormal posture.1,2,13-15 The efficacy of various posture correction techniques has also been reported.17,18,22 Posture correction is a highly specialized field of evidence-based medicine. It is not, or should not be, intended to treat a wide variety of human ailments. There are many techniques in the chiropractic physician’s armamentarium that can effectively treat many types of ailments.
Posture correction is the true epitome of a neuromusculoskeletal specialty, based upon the comprehensive nature of posture correction, which involves all of these systems, nervous, muscular, and skeletal, equally. “Straight” chiropractors who provide only spinal manipulation are not, in fact, NMS specialists. Articular manipulation does not address all three components inherent in the spinal system. Therefore, these practitioners may be considered as providing a type of therapy, similar to joint mobilization provided by massage therapists or physiotherapists. Additionally, many of these practitioners refuse to determine, through appropriate diagnostic testing, if spinal manipulation is, in fact, reasonable and necessary for each respective patient. We have recently seen the end result of this shortsighted attitude with the revocation of accreditation at Life University. If posture correction is to remain a part of traditional chiropractic, then it may see the same potential fate as “straight” chiropractic. Unfortunately, questionable practice behaviors, including unprofessional advertising, excessive patient billing, unnecessary procedures, and the promotion of unscientific principles may lead to professional ostracism and isolation.19 The question remains; will posture correction stay a part of this unscientific charade?
Other disciplines, such as physical medicine, orthopedics, physical therapy, and even alternatives like the Alexander Technique, all understand the importance of good posture. These disciplines also consider the potential health risks of poor posture. Posture correction is addressed in many forms of healing, both traditional and alternative. However, posture correction is currently viewed only as a portion of each specialty. Posture correction, as stated earlier, can only be effectively delivered by practitioners who have specific and appropriate training. Therefore, it should be classified as a specialty in and of itself. As long as chiropractic education and practitioners remain in the unscientific realm, posture correction must be aggressively pursued as a separate specialty from chiropractic, perhaps a subspecialty of evidence-based medicine.
Posture Magazine July 2003 issue
1. Cailliet R, Gross L. The rejuvenation strategy. Doubleday & Company, Inc. 1987 pg 50-59
2. Cailliet R. Neck and arm pain. F.A. Davis and Company 1964 pg 9-59
3. Mattox TF, Lucente V, McIntyre P, Miklos JR, Tomezsko J. Abnormal spinal curvature and its relationship to pelvic organ prolapse. Am J Obstet Gynecol 2000; 183: 1381-1384
4. Winterstein J. Expanding our vision. J Chiropr Med 2002 1: 1-2
5. Kremer RG. Strength in diversity: Professional and legislative opportunities in primary care by the recognition, defining and promotion of the licensure of chiropractic medical education, competence and skills. J Chiropr Med 2002; 1:139-148
6. Crelin E. A scientific test of the chiropractic theory. American Scientist 1993;61:574-580
7. Homola S. Is the chiropractic subluxation theory a threat to public health? Scientific Review of Alt Med 2001; 5: 45-53
8. Riekeman G. We all have a historical connection to palmer chiropractic, and a stake in keeping our profession pure for the future. Dynamic Chiropractic Online. Jan 25th, 2000 www.chiroweb.com/columnist/riekeman/
9. Nilsson N, Christensen HW, Hartvigsen J. Lasting changes in passive range of motion after spinal manipulation: a randomized, blind, controlled trial. J Manipulative Physiol Ther 1996;19:165-168
10. Nasel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manipulative Physiol Ther 1995; 18:479-497
11. Hawk C, Long CR, Boulanger KT. Prevalence of nonmusculoskeletal complaints in chiropractic practice: report from a practice-based research program. J Manipulative Physiol Ther 2001;24:157-169
12. Harrison DD, Janik TJ, Troyanovich SJ, Harrison DE, Colloca CJ. Evaluation of the assumptions used to derive an ideal normal cervical spine model. J Manipulative Physiol Ther 1997;20:246-254
13. Troyanovich SJ, Harrison DE, Harrison DD. Structural rehabilitation of the spine and posture: Rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther 1998; 21: 37-50
14. Harrison DE, Harrison DD, Troyanovich SJ, Harmon S. A normal spinal position: It’s time to accept the evidence. J Manipulative Physiol Ther 2000; 23: 623-644
15. Harrison DE, Cailliet R, Harrison DD, Troyanovich SJ, Harrison SO. A Review of biomechanics of the central nervous system-part III: Spinal cord stresses from postural loads and their neurologic effects. J Manipulative Physiol Ther 1999; 22: 399-410
16. Evans R, Bronfort G, Nelson B, Goldsmith CH. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine 2002; 27: 2383-2389
17. Morningstar M. Cervical curve restoration and forward head posture reduction for the treatment of mechanical thoracic pain using the pettibon corrective and rehabilitative procedures. J Chiropr Med 2002;1:113-115
18. Harrison DD, Jackson BL, Troyanovich SJ, Robertson G, DeGeorge D, Barker WF. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. J Manipulative Physiol Ther 1994;17:454-464
19. Wickes D. Educating primary care chiropractic physicians. J Chiropr Med 2002; 1:175-179
20. Seaman D, Troyanovich S. The chasm between posture and chiropractic education and treatment. Dynamic Chiropractic Online www.chiroweb.com/columnist/seaman_troyanovich/
21. Littrell TA. False-positive and false-negative errors in chiropractic clinical intern radiological reports. Platform presentation, association of chiropractic colleges’ ninth annual conference. J Chiro Ed 2002; 16:31
22. Saunders ES, Woggon D, Cohen C, Robinson DH. Improvement of cervical lordosis and reduction of forward head posture with anterior headweighting and proprioceptive balancing protocols. J Vertebral Sublux Res (In Print)