Thank you.
SPEAKER_02:I'm never opposed to postural change, never opposed to working on doing some alterations in the person's experience. I think the biggest difference from at least what I was taught in university and how I approach it now is that I don't go chasing anterior pelvic tilt and looking to change it as the first line intervention or telling my patient the reason for their pain is that they have anterior pelvic tilt.
SPEAKER_01:Does anterior tilt matter and does posture matter? These are the questions we explored with Mark Sudeika and Sam Spinelli from E3 Rehab. What was beautiful about this episode is we really looked into the when. When would we ask these questions about posture and anterior pelvic tilt? When might we explore the patient's beliefs in a static position or in a movement performance position and the nuances between someone experiencing pain and someone who is looking to improve performance, but also just by mechanics and mechanical advantage. Should we change someone if they're wasting energy, they're not moving efficiently, or should we only change someone when they're bringing forth some pain or some niggles or some subjective complaints? Really great nuance in this episode. Please check out E3 as well for wonderful blog, podcast, and YouTube playlists. My name is Michael Risk, and this is Physio Explained. All right. Welcome, Sam and Mark from E3 Rehab. We're going to get into an episode around anterior pelvic tilt, but thank you, boys, so much for joining us today. Thank you very much for having
SPEAKER_00:us on. We appreciate it. Yeah, looking forward to it.
SPEAKER_01:That first voice you heard was Mark, and that second voice you heard was Sam, and Mark tells me that this is more of a Sam topic, so I might start with you, Sam, but... Let's start with the assessment of anterior pelvic tilt because there is a little bit of nuance around it and there is maybe a false dichotomy around it. When are you looking at anterior pelvic tilt? When is that important to you? Is that something you look at with everyone who you come into contact with? Yeah,
SPEAKER_02:if I'm being completely honest, I pretty much never directly assess it. I might give a general visual observation and awareness of it, but I'm not pulling out a goniometer or trying to do some sort of postural scan on it. just a general awareness. If someone discusses it and brings it up, I'm going to take note of it. Otherwise, it's generally something that I just leave as it exists. And we're going to only come to it if it's brought up by the patient or might be something that we look to adjust, which we're going to get into later on in certain cases. Yeah,
SPEAKER_01:I think that's reasonable. And when you say you might not measure it. Is that because you don't feel it's super important or you don't feel that measuring it is actually that relevant or even accurate? Yeah, I'd say
SPEAKER_02:probably both. From a standpoint of measuring it, we can be pretty confident that the ability to measure it is quite poor. Just about every measurement option that we have. Then from a standpoint of usability, it's difficult to change, at least in a consistent basis. It's going to be questionable if the utility is there to change it from a standpoint of pain, from a function standpoint, which we're getting into as well. You might make a different argument, but in general, I just don't see that it brings a lot to the table to directly assess it if I don't plan to directly change it.
SPEAKER_01:Yeah, yeah. I always think back to the lower cross posture that I learned at uni and the big crossover someone's body where it might suggest they have, I think it's tight hip flexors and then they would compress their facet joints at the back. So if there's younger health professionals listening and someone might present with that low back pain that feels extension-y or facet-y and they do appear in a static anterior pelvic tilt, and maybe they even know that, maybe they say, I think it's because I'm forward or my back has more low doses. Is there anything you do specifically? Do you try and meet them in the middle? Do you have a certain explanation? How do you deal with that patient that presents like that?
SPEAKER_02:Yeah, I think that the short answer there is that I'm never opposed to... Postural change, never opposed to working on doing some alterations in the person's experience. I think the biggest difference from at least what I was taught in university and how I approach it now is that I don't go chasing anterior pelvic tilt and looking to change it as the first line intervention or telling my patient the reason for their pain is that they have anterior pelvic tilt. If a patient says, oh, I feel like my anterior pelvic tilt is an aspect of my back pain, I'll have a discussion about that anterior pelvic tilt is common, not necessarily a problem, but I'm open to exploring how we can make some changes if they find that when they are anteriorly tilted that there's discomfort, how we can modify that anterior tilt so that they can get out of the position, have a little bit of time away from the discomfort, and then gradually work on integrating it back in.
SPEAKER_01:Yeah, that's a beautiful and sensible approach. I like that you're meeting them where they are and you might provide the temporary change And that could give you some guidance in the early treatment, but you're not pinning their pain on that particular posture, more that we can play with it. Mark, did you have something to add to that?
SPEAKER_00:Yeah, I just wanted to mention that I think it's always important to explore the person's belief or their beliefs. So if they come to you stating that they have back pain and they think that their back pain is associated with their posture, you know, that's probably something that you want to dig a little bit more into. I might not give My beliefs, you know, right off the bat, I might ask them, well, why do you think that's the case? And then maybe they've listened to a podcast or they've watched a YouTube video or they've seen a social media post. And that just helps you better understand their position. So you can have that discussion with them in terms of its relevance to their symptoms and their function. I
SPEAKER_01:like that. I want you guys to tear me to shreds here, but I recently went into bat for posture, even though the narrative has been posture is not linked to pain. And I'd noticed I'd been sitting a hell of a lot more. My work had almost completely changed from being a standing physio to five days a week at the desk. And I said, this thoracic pain I've developed, it is inherently, in my experience... never be able to prove by research, linked to the change in my posture. And so there was some nuance in that because I felt like definitely when I flexed my thoracic, it triggered it. When I treated around my thoracic or got into extension, it felt a lot better. So in my experience, the two were linked. Then I think that this higher level argument that there's a web of determinants of pain and we could never pin someone's pain on exactly one thing. It might just be contributor. So I was going to bat saying posture was important for that N equals one for me in that situation. And probably with more nuance, it's not the posture per se, but the change in load. It's not that this is inherently bad. It's that I went from this to flexed five hours a day and I was standing before that. Is there any nuance in that or things that you would add to that or points that you might highlight? I'll start with Sam and then I'll throw to Mark.
SPEAKER_02:I think you hit that nail on the head there when it comes to that example of where if you shift from predominantly being one position to predominantly being another, there will be a change in demands, the tissues that are being stressed, the type and position that are going to be challenged. And if you're not used to that, it's understandable to have some discomfort with that. I don't know if you guys have ever heard the analogy that's often given. This is something that's used a lot in the lifting circles. But if you have someone go and start a job as a garbage man, they're going to be really sore. They're going to be really tired the first time that they do it. But if they just continue doing it, they're going to get used to it. And I think that's a fair analogy that explains the general accommodations that we have with things, the repeated bout exposure, that if something is new or the volume, the stressor or the intensity, et cetera, is new to you, well, then repeated bouts of it, you're going to get more and more adjusted to it over time. On the flip side, yeah, there's no inherent problem of also discussing with, for instance, in your case, okay, well, it might be beneficial for you to try to alter the volume and time that you're spending in this position if you can't tolerate it, because we don't necessarily need you to just spend your day in agony if it's so debilitating for you. And so it's not that being rounded all day long is inherently bad, but In your case, you just can't tolerate it at the moment and you might build up to it over time. But in the meantime, let's explore some ways that we can give you some options for sitting, standing, altering your position so that you can get through your day.
SPEAKER_01:That makes a lot of sense to me. And I think when I was going into BAT to say that posture was important, I think I was coming at it from a new grad perspective that there was many new grad physiotherapists on ground in Sydney that I work with that were almost... not questioning it, not asking it, or not exploring their patient beliefs around it because they'd been hit with the message that posture isn't important. So maybe it's still an asterisk sign. We still discuss it. We still dig into patients' beliefs. And your narrative seems to be changing load, changing postures rather than one bad posture. What were your thoughts on that, Mark?
SPEAKER_00:Yeah, I think Sam and I take the stance that we're not saying that posture never matters, but it's our explanation as clinicians to the people that we're working with that really matters. You know, I'm at my standing desk right now. And if I were to position myself into my end range, you know, anterior pelvic tilt and hold this position for the entire day of this talk, I might experience a little bit of discomfort and I would want to move out of that position. Similarly for you, I might just explain, or we have this discussion of why you think that sitting and the position that you're in is causing you discomfort and find strategies to ameliorate that, whether that's incorporating standing breaks, walking breaks, or if you notice associations. I don't notice it when I'm watching my favorite Netflix show with my family, but I notice a lot more when I'm working and I'm stressed. So like you said, it may be a contributing factor or an association, but we just don't want to say that it's causative and then... give the impression that that posture or that position needs to be quote-unquote fixed because it's bad or wrong. It's just a position. Posterior pelvic tilt, anterior pelvic tilt, they're just positions that everybody moves in and out of on a regular basis.
SPEAKER_01:I like the nuance you applied there. And also, that was a wonderful analogy that They may be in the same position, but in different scenarios. And one scenario causes them some discomfort and the other scenario might not. That's a great thing we could highlight in our subjective history. Let's shift to dynamically or for performance. So if someone's potentially deadlifting or squatting and they either move into anterior pelvic tilt or they live in anterior pelvic tilt, does this change your conversation? or what you might do with someone when we're talking about lifting or performance. I'll throw it to you to start, Sam. Yeah, I
SPEAKER_02:think the first thing I've got to understand, at least in this context of squatting and deadlifting, it's pretty unlikely that the person will maintain an anterior pelvic tilt. If we look at the actual pelvic mechanics during a squat, if you are starting in an anterior pelvic tilt, you're going to be leaving it real quickly. In the case of a deadlift, if you're starting in the bottom, You won't be an anterior tilt. And if you try to anterior tilt at the top, that's pretty awkward. And you might be able to do it, but probably not going to enjoy it. From a performance standpoint, I don't think it inherently is a disadvantage in the squat. Maybe. However, in the deadlift, I think that from the general research that we have so far looking at how strong you're able to produce forces in deeper ranges of lumbar flexion, Attempting to be an anterior pelvic tilt would be a disadvantage just because then it would take you away from flexion since it'll be a coupled action, which that can be challenging for some individuals. I know that when I speak with powerlifters and weightlifters, they often have this connotation that having any degree of flexion is a negative aspect and discussing with them the nuance there is very challenging. But if we're looking at it from a pure performance standpoint, I don't think that anterior pelvic tilt brings a lot to the table for lifting. I think if we get into other sports, it's different. But in the case of lifting, at least not really any benefit.
SPEAKER_00:Yeah. I think my mindset is similar to what we just talked about with what's sitting in the sense that we're talking about technique somewhat. And it's the same idea that we're not saying that technique never matters. either. You know, I know that Sam occasionally experiences symptoms associated with FAI, and I occasionally experience symptoms with my hip as well. And for me, if I'm at the bottom position of the deadlift when, you know, my hips are relatively flexed and I try to maximize my amount of anterior pelvic tilt, I actually get a pinching sensation in my hip. So I purposely avoid Whereas others might say, you know what, you actually need to maximize that because you want a flat back and a stretch in your hamstrings, etc. And maybe for somebody else who experiences different symptoms, that is the appropriate strategy for them. But for me, because there is such a wide variability in technique, that's not the strategy that I use. And it's not the strategy that maximizes my performance or how I function.
SPEAKER_01:Yeah. Yeah. Really good analogies. I think these are the conversations that need to be had. It's the when conversation, like when would we look at that rather than just it's not important or it is important. That's a beautiful nuance you're bringing there, Mark. A thought I had was what about when someone is rapidly moving through a posture, say, from lordosis to kyphosis in their lumbar spine? Is that something you would look at either now if they're experiencing pain or just from a biomechanics standpoint. So maybe they start really flexed and they go into extension or vice versa. Is that something that ever concerned you? I remember in a younger, potentially female CrossFit type population in my early days, there was a lot of variation in what they would do through a movement. And my very young physio brain was like, if we can just limit some of that movement, that might help for both performance and pain. Where are you guys sitting on that thought at the moment? I'll start with you again, Sam.
SPEAKER_02:Yeah, it's a good one. I think from a standpoint of pain, I'm less concerned with it unless the person is expressing that that distinctly is a trigger for them. For instance, something like a wall ball is a good example where in CrossFit, they're often going to be extending over the top and singing down deep ranges and probably going through that more rapid cycle. If they're saying, okay, well, when I do a wall ball, I find it very provocative, whereas if I do a slow, more static back squat, it's not as much of a trigger, then I might lead towards considering having a discussion with them about trying to minimize some of that motion. However, like Mark discussed with the example of sitting earlier, it's going to be dependent upon those factors, not that I just inherently think it's a problem, and also looking at the load that's brought in into the situation. Whereas in the case of performance... Yeah, I think it's difficult because it's just going to vary. However, you could make an argument that unnecessary motion is going to be something where they're expending additional energy that's not their advantage. And if they, for instance, find that their back fatigues out during these types of Metcons or different movements, well, that might be a reason why. And then looking to alter that. However, I do think that changing it would be very challenging. And you might be able to spend your energy and time on just improving their general endurance better, but it's a reasonable road that you could travel down.
SPEAKER_01:Yeah, I like that. I'm often caught between the mechanical advantage of a movement and losing or wasting energy versus what that patient's already adapted to. So if their movement's a little sloppy or there's extra movements or wasted rotations or wasted energy, They've adapted to that. So potentially their system is okay with that. But then there's a biomechanical point where you think it could be cleaner. Then it's almost a question of what's the effort to change it. And if we change it, does their O2 actually go up? Their oxygen consumption go up? Do they start sweating more? Is it a harder movement? It's a question I often ask with runners. Do you have any helpful points to work through that scenario? If someone is wasting a bit of energy, do you coach them towards it? Or would you only coach them towards it if they are reporting a problem?
SPEAKER_02:Yeah, at least my general bias in that situation is to shy towards not changing the technique unless it is for some reason going to be a distinct benefit. I think running is a good example there where you can see that alterations in running technique often don't actually have a high benefit for running economy. So if I'm going to change your technique, it's not necessarily going to provide much return on that efficiency from the amount of energy utilized, oxygen consumption, consumed, etc. So I'll probably just shy towards just making you more fit overall, which would probably have more transfer. Now, this might change in extreme cases where someone has like a wild technique that maybe is for some reason concerning. However, yeah, I think if you watch a lot of sports and you look in situations of extremes, you'll find people that do some really peculiar techniques and still are extremely successful. Same when you start to look into adapted sports, where people inherently have to have different techniques and can still do things really well, even near world record performances, non adapted sports. So I think that we often can fall into a trap of believing that the biomechanics that we perceive are the best are the best when they might not necessarily be even when we look at an individual level or a population level.
SPEAKER_01:I love that. Sam and Mark, you've brought such wonderful nuance to this conversation. It's an old conversation, but I'm actually finding this really helpful and I know the younger audience is finding it really helpful. The examples of when you would go down one route versus another rather than just saying anterior pelvic tilt is X or posture is X. So thank you so much for your time today, gentlemen. And please check out the E3 Rehab website if you haven't already. Wonderful blog, wonderful podcast, wonderful YouTube. I was saying off air that the YouTube is organized into beautiful playlists as well where you can go deep on a topic. So once again, And thank you for exploring this topic with me. And please check out the E3 website. Thank you, Sam and Mark.