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Expert Critique

FROM THE ASCO Reading Room

Anny Wu, D.O. Rheumatologist Adventist Health

The etiology of pain associated with fibromyalgia is often multifactorial and debilitating. To mitigate symptoms, mind-body exercises such as yoga and pilates that improve posture and provide core strengthening have been prescribed. It is not a surprise then that altered trunk posture may play a role as well in fibromyalgia. In the study by Sempere-Rubio et al, larger thoracic kyphosis and baseline shoulder protraction were found to be present in patients with fibromyalgia. These patients also had a harder time maintaining an erect sitting posture.

Although the data are inconclusive, physical exercise that seeks to correct this deficit may be beneficial. At the very least, the posture seen in fibromyalgia patients may be attributable to the nature of the condition as sedentary lifestyle was found to have no particular effect on trunk posture. Whether these structural abnormalities are secondary to pain or other processes will need to be examined. However, altered trunk posture can be considered a feature associated with fibromyalgia that may complement existing assessments of the condition and require specific treatment.

Full Critique

A new report indicates that patients with fibromyalgia display altered trunk posture. Although some experts cautioned that the results are not conclusive, they could still provide a new blueprint for incorporating trunk posture into assessing and addressing the condition.

Published in April in the journal , the investigation studied 118 women with fibromyalgia and 110 patients without fibromyalgia. Scientists assessed thoracic kyphosis, forward head position, shoulder position, shoulder protraction, and the patient's ability to maintain cervical and thoracic angles.

Researchers used the Independent Student's t-test and MANOVA tests to analyze differences in body positions. The mean age was 54.36 years for the fibromyalgia group and 54.76 years for the control group (P>0.05). Body mass index for the fibromyalgia and control groups was 27.31 and 25.66, respectively. Exclusion criteria included a history of fractures or spine surgery, inflammatory rheumatic disease, neurological disorders, peripheral neuropathy, or acute or terminal illness. After an examination, a physiotherapist classified participants as "sedentary" if they participated in no physical activity.

Results showed significantly larger thoracic kyphosis and baseline shoulder protraction in the fibromyalgia group, as well as lower craniovertebral angles compared with the control group (P<0.05). Sedentary lifestyles had no disproportionate effect on trunk posture in patients with fibromyalgia.

Fibromyalgia patients did exhibit impaired ability to maintain cervical and thoracic angles over five minutes. In a prolonged sitting posture in the cervical and thoracic posture angles, the fibromyalgia group showed significant differences in every minute until the last (i.e. T4-T5). The control group initially showed differences (i.e. T0-T1) but then sustained both angles through the remainder of the test.

"The [fibromyalgia] female population present an altered trunk posture and an inability to maintain trunk position," wrote study co-author Pilar Serra-Ano, PhD, of the University of Valencia in Spain, and colleagues. "[Trunk posture changes] are manifested with a curved posture, with hump (hyperkyphosis) and with a forward position of the shoulders, which also involves a forward position of the head, as if they maintained a posture of alertness...Since this does not appear to be influenced by a more or less active lifestyle, specific treatment programs are needed to manage this clinical condition."

Clinical Implications

A connection between fibromyalgia and posture would not be a new phenomenon, and good posture is recognized as a key tool in managing pain, stiffness, and fatigue. As a result, many physicians incorporate posture into the treatment strategies they design, frequently recommending physical or occupational therapy.

This study, however, goes a step further, the study authors said, because of its findings on trunk posture and the template it offers for assessing posture in a fibromyalgia context.

"Those responsible for the clinical care of these patients should not just pay attention and assess the postural alteration of these patients in order to know their level of misalignment and muscle weakness," Serra-Ano said. "They should also recommend therapeutic physical exercise that promotes the correction of postural alterations and seeks muscle conditioning, making them more flexible."

Altered trunk posture in particular has a cascade effect for patients with fibromyalgia, exacerbating the condition's primary symptoms.

"This advanced posture of the head has a series of harmful consequences such as increased muscle tone of the cervical muscles and therefore the irritability of the muscles," Serra-Ano said. "Likewise, it has been observed that...women with fibromyalgia are not able to maintain their erect sitting posture for a period of time of at least 5 minutes."

Instead of addressing the disease based largely on less-tangible means, these findings could give clinicians a new tool for individualizing the treatment plan.

"This syndrome is usually characterized using questionnaires or scales, given the multifactorial nature thereof," Serra-Ano and colleagues wrote. "However, this condition has physical consequences, such as the associated trunk posture, that can be evaluated with objective tools and used as supplementary information...Postural assessment is highly important in the evaluative process in individuals diagnosed with fibromyalgia syndrome."

Once the posture of a fibromyalgia patient has been characterized, that information can inform new or existing treatment strategies. Physical therapy and strategies that focus on posture correction can help the body avoid unnecessary stress, which in turn can reduce pain and fatigue in fibromyalgia patients. Assessing trunk posture, Serra-Ano said, can lead to more effective disease management.

"If we know that the patients have a postural attitude in which their shoulders and head are placed in a forward position, we should be able to promote adapted therapeutic programs which in general focus on the stretch of anterior trunk muscles and strengthen the erector and interscapular muscles," Serra-Ano said.

At the same time, there is some uncertainty about the study. Roland Staud, MD, a rheumatologist with University of Florida Health who was not involved with the study, called the findings "a good first step," but said it was premature to make any clinical recommendations based on these findings alone.

"What the investigation tried to allude to is that if fibromyalgia treatment is better, the posture will taken care of," Staud said. "But the posture could be related to pain or having less function."

The study data warrants additional study, according to Staud, but factors like height, weight, pain reportations, and socioeconomic status should be included moving forward.

Regarding additional studies, Serra-Ano and colleagues wrote that "the results of the study could be further supported with the acquisition of electromyographic or tensiomyographic data that would be helpful to relate trunk posture impairment with muscle activity and muscle properties."