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The Posture Series

Posture New Approach
Look what simple posture does to your appearance! (It’s not the glasses that hid Superman)

As a sports medicine and pain specialist who focuses on the neck, shoulder, and back issues, posture has been an essential part of my practice. In my office, our evaluation of posture plays an important role in both diagnosis and monitoring improvement in all the treatment protocols we prescribe. Years ago, I started a posture app that was available on the Apple store as Posture Check. There are a few people out there who still remind me that they have the app even though it hasn’t been updated for years.

Then about 5 years ago, I started a posture blog on the Google+ platform and had close to 80,000 followers. It was the #1 posture blog worldwide in the Google+ platform and was listed on their ‘featured’ page. Many of those articles are still available on my website and are still full of valuable outdated information.

What I believe is important in posture has changed over the last few years. If you were to read my articles concerning posture, you would see a pattern where I was extolling people to draw their tummy in and rotate their pelvis under them. Then work on building the endurance necessary to maintain this position all day. Now I would tell you the exact opposite.

In the past few years, our understanding of muscle tone has changed. Instead of asking muscles to contract all day, we instead strengthen muscles and then expect the tone, or resting contraction of the muscle, to increase over time. Think of the arch of the foot. You aren’t holding your arch up, but the tone of the muscles in your foot is holding your arch in place. The same goes for your posture. We expect you to assume the correct position, and then relax.

When I was telling people to draw their tummy in and rotate their pelvis under them, I was creating tension in the body and in their muscles. I like to say that the people who did exactly as I instructed were essentially holding in a fart for 16 hours a day. This breathe holding and muscle tension is not good for your body. Do we want your posture muscles strong? Of course, but this is not the way to do it.

When we evaluate low back pain, one of the things we look for is whether someone has begun to breath-hold with activities. It speaks to an altered stabilization pattern and identifies weakness. By creating breath-holding in patients trying to improve their posture, we may have been worsening their stabilization and causing motion (or lack of motion) patterns that weren’t helpful. One of the things we try to accomplish in physical therapy is the elimination or severe reduction of these breath-holding moments. I was creating breath-holding days.

Now the recommendations go like this. Sit up straight, draw your shoulders back some, allow an arch in your back and try to position your head over your shoulders. Now take a deep breathe and relax. Let your butt cheeks relax. Keep the same position, but just do it relaxed. You were made stable, let the muscles that are supposed to stabilize you do it without all the tension. In a more straightforward explanation: sit up straight and then breathe.

I will explain more over the next few months, but for now, let us just start with that. Now, for the people who followed my advice from my previous posture articles, go outside, find a place away from others and let yourself relax.

Sean Wheeler, M.D.

The POSTURE Series, No. 5

By Sean M. Wheeler, M.D.

IMG 6003Chronic Back Pain Specialist Dr. Sean WheelerOur spines aren't designed to live as we today do. 

Our early ancestors sprinted barefoot across the savanna, spear in hand, the picture of perfect ergonomic position. In contrast, today we sit much of the work day at a desk, hunched over computers and phones. 

However, the evidence is clear: standing longer, when in correct posture, is better for us than sitting.  

Standing in this way reduces risk of obesity, diabetes, cardiovascular disease, cancer and lowers long-term mortality. In contrast, extended sitting causes us to slouch, tightens our hip flexors, rounds our shoulders forward and causes pooling of blood in our legs and feet. 

Standing strengthens our feet, calves and gluteus and puts us in a better posture.

The standing vs. sitting choice sounds obvious I gave it a try. I found boxes and outdated medical books on which to prop my computer screen and mouse. Ten minutes in I was feeling good. By 30 minutes I knew something was wrong and sat down. I was not ready for all-day standing, and in all likelihood neither are you.  

Recent studies, including a medical review published in the Cochrane Library, show that people don’t stand much longer with a standing desk and the standing they do is marked by bad posture. This outcome has much to do with bracing muscle® function.

Bracing muscles in the buttocks stabilizing the hip provide endurance for stabilization during standing, and under-utilized bracing muscles have to be built-up by standing with proper posture over progressively longer periods of time. Running or working out will build strength in the action muscles of the buttocks that move you, but not the endurance needed for stabilization during standing.

If you think you can suddenly just stand all day, you may end up as the above study suggests: sitting.

You can test your readiness for a stand-up desk at work while otherwise waiting in a long line that doesn't seem to move, or after you've arrived late at a function and all the chairs are taken.


Stand with equal weight on both feet without locking the knees and without leaning forward. For a more complicated task, draw your tummy in, bringing your pelvis under you. Then keep track of how long it takes until you lean into one hip. This period of time is how much endurance you have in the bracing muscles of your gluteus.  Typically this period of time is not long. Once you begin to lean, the foot, knee and hip on that side get sore. This is not what you want. In fact, the leaning is actually worse for you than the sitting.

To achieve the ultimate goal of all-day standing at work, and the health benefits that come with it, budget your standing time as you build the necessary endurance. Stand until leaning, then sit. Time this out daily, slowly adding more and more non-leaning time until the day is filled with proper standing. By the way, propping yourself up, bent over the desk, doesn't count. 

Using this better posture you will soon be standing significantly longer. Expect the entire process to take up to six months, as that is the period endurance muscles require to rebuild blood flow for all-day endurance. 

Think of it like this: you have to climb the mountain before you can stand triumphantly atop it.


Sean Wheeler, M.D. is board certified in both Pain Management and Sports Medicine. He is a leading expert on back pain. His recently released book, UPRISE, is changing the way the world thinks of back pain causation and its treatment. With a new vocabulary in aid of understanding the cause of back pain, and new medical approach focused on increasing the endurance of your bracing muscles, Dr. Wheeler puts patients back in charge of their health to achieve liberation from chronic back pain. 


The POSTURE Series, No. 4

By Sean M. Wheeler, M.D.

There is a difference between a teenager slouching and an adult slouching.

It is gratifying, as a nagger [a skill learned from my mother] to constantly bug a teenager about slouching and watch them follow your advice and obtain great posture. Gone is the insecure 16 year old and in their place is the confident 19 year old.

One can’t help but to look upon that young adult and feel a sense of pride in the constant badgering that accomplished such a feat. And yet, the same adult is unable to fix their own posture. Braces, electronic reminders, Lenten resolutions, shock collars, etc. and nothing seems to stick. Sure they sit up taller for a while, but the head is still forward and the middle of the back begins to hurt. It is not lack of willpower, no matter how much one beats themselves up over their posture.

Something has changed.

The fundamental make-up of a teenager slouch verses an adult slouch is completely different. Until the adult is able to understand the difference, they will always have posture problems.


The tissue isn’t the same.  We joke as adults that a child can stab themselves with a fork and watch themselves heal, but adults pull a muscle putting their belt on and two weeks later they still hurt. It is only funny because it is so true. A young person’s tissue just holds them together better.

Imagine a huge tent for a wedding that has a single large pole in the center. The cloth of the tent is new and taunt. The ropes and stakes that support the tent are strong. The whole structure is stable. Then someone runs into the center pole hard enough to make it wobbly. The tent as a whole is not as stable as it was, but because the cloth and the ropes and stakes are in such good condition, enough stability is maintained to make the tent functional. [This is the case of a young adult who begins to lose their bracing muscle strength.]

As the tent ages, the cloth begins to give a lot more. Tears easier and cannot be relied upon as much to provide stability. The ropes stiffen and become more brittle while the stakes bend. In an older tent, a wobbly center pole becomes an issue that must be dealt with if the tent is to stay up. [Please no comments on tent repair or stability, this is a parable on the aging body, not a treatise on tents.]

When injuries or bad positions occur, adolescents spring back into position like a Weeble. ["Webbles wobble but they don't fall down."] Adult tissue is like the part of the couch that one hates to sit on, because they sink in way too far. It is just not the same tissue.


Gluteus muscles are weaker. The muscles in the buttock that hold the leg into the hip in a stable position are bracing muscles. Muscles that have to work all day stabilizing the hip joint. As adult sits at their job, or find increasingly more efficient ways of completing their jobs, they slowly begin to lose the endurance of these bracing muscles. Sure, the gluts are still strong, but how is their endurance? When standing, how long until they lean into one hip? This is a sign of endurance in the stabilizing function of the gluteus. When the gluteus is weak, psoas tightens [see The Posture Series, No 3].


Pelvis is in the wrong position. Adults not only sit more, but have better chairs. Kids sit in terrible chairs and can’t wait to get out of them. Adults take their hard earned money and get the chairs they deserve. Then they lean back into them. They role their pelvis back, allow their tummy to pooch out and sit like this for hours. The days turn into weeks and months and then years and decades. The pooched out tummy becomes a norm that one would never see in teenagers. It becomes a sign of decreased deep bracing muscle strength around the lumbar spine. A teenager with their pelvis in the wrong position is okay because their tummy is drawn in all the time. An adult has to have their pelvis in the correct position because of this lack of endurance in the tummy muscles (not situps).

Adults then try to get their posture back and think all they need do is make a commitment to sitting up straight. Instead, getting their pelvis in the correct position is going to take a serious 180-day commitment to drawing the tummy in correctly, stretching hamstrings and hip flexors, strengthening the gluteus bracing muscles and deep bracing muscles. Add to this, knowing where the pelvis is supposed to be, rather than pretending they have an adolescent slouch.


These steps might even make putting on a belt less dangerous to one's health.


[Weebles is a trademark for several lines of roly-poly toys designed by Hasbro‘s Playskool Division.]

Sean Wheeler, M.D. is board certified in both Pain Management and Sports Medicine. He is a leading expert on back pain and his recently released book UPRISE is changing the way the world approaches back pain. With a new vocabulary and new medical approach, Dr. Wheeler puts patients back in charge of their health to achieve liberation from chronic back pain. 

The POSTURE Series, No. 3

By Sean M. Wheeler, M.D.

In part 2 of our Posture Series I explained how to get your pelvis in the correct position. This correct pelvic position is the essence of good posture, to assist in avoiding chronic low back pain.

Drawing the tummy in, pulling the pelvis into the correct position, achieves good posture and builds the endurance strength to the very muscles which stabilize the spine.

Psoas Quadratus LumborumPsoas & Quadrates Lumborum
The concept may sound simple, but so much could go wrong.

Two Muscles At Work

There are two muscles around the spine called psoas and quadratus lumborum that work to lock the low back into a fixed position.

The psoas [red pointer in the image] runs up from the hip along the front of the spine and attaches to the spine above the level of the belly button. It is a very strong muscle that helps stabilizes the hip and causes many problems when it is not functioning correctly.

The quadratus lumborum [blue pointer] is a smaller muscle that runs from the top of the pelvis to the lowest rib, and most of the time, works with the psoas to lock the spine down.

Dr Sean Wheeler Locked Down SpineCollege student to-be practices moving to campusHeavy Lifting

Most of the day your spine is stabilized using deeper muscles called bracing muscles that stabilize while allowing normal motion of the spine.

When you pick up something heavy, this is the only time you switch to the psoas and quadratus lumborum. They provide an extra level of stability needed during lifting. So in a perfect world, 99% of the day your bracing muscles stabilize you and 1% of the day the psoas and quadratus lumborum lock you down to lift something heavy.


With back pain, sometimes the psoas goes into spasm in a failed attempt to protect the back and hip. When the psoas spasms, it pulls the pelvis into a poor position and the lumbar spine forward. 

DrSeanWheeler Pelvis Position Illustration2The quadratus lumborum is then forced to contract all day to fight this spasm and it leads to irritation of the quadratus lumborum and muscular back pain.

Some people who have back pain then have two problems, the original cause of pain, plus the body trying to stabilize them further and causing more problems.

How can you unintentionally cause psoas spasm? By drawing your tummy in too forcefully when attempting to get your pelvis in the right spot. In this case, improving your posture can actually lead to back pain.

What To Do

Here’s what you do: draw your tummy in to pull your pelvis into a correct position where your head feels comfortable over your shoulders. Then rock your shoulders side-to-side to see if your lower back feels locked down. If it does, take a deep breath and start over.

Over time this will become easier and feel much more natural. Holding this position all day is very difficult as it takes bracing muscle endurance and that endurance strength takes 6 months to achieve. So be patient and persistent.

When To See A Medical Professional

If all of this sounds like gibberish and you can’t get your pelvis to do any of these things, you may need to see a professional. If your back is locked down when not heavy lifting and you suspect your psoas is in constant spasm, you may need to see a professional. Otherwise, let’s keep following this path towards better posture.

More To Come

Coming soon, why adult posture problems are different than those of the teenager.


Sean Wheeler, M.D. is board certified in both Pain Management and Sports Medicine. He is a leading expert on back pain and his recently released book UPRISE is changing the way the world approaches back pain. With a new vocabulary and new medical approach, Dr. Wheeler puts patients back in charge of their health to achieve liberation from chronic back pain. His oldest son Duke tried to imagine that he was lifting the pictured box while moving to college, but at the time of this column, he still has 4 months to wait.

The POSTURE Series, No. 2

By Sean M. Wheeler, M.D.

What brings any of us to a point where we are compelled to read an article about posture?

So instead of reading another article, why not just sit up straight?

If only.

In this second in a series, let's discuss the importance of pelvis position in good posture, and how poor pelvis position may indicate a deeper health concern: the possibility your body is losing its bracing functionality. A functionality vital to living without chronic back pain. 

Challenging Assumptions

One can set their phone to remind them to sit up, find a wearable device attempting to pull you into the correct position, and even special seats for posture assistance. New posture reminder devices are coming out all the time and yet…this article exists because good posture remains difficult to achieve.

Let’s start by challenging current thinking. One can’t just sit up straight to solve their posture problem. Not when the pelvis is in the wrong position.

Pelvis Tilted Forward

Dr Sean Wheeler Posture Pelvis ForwardPelvis forward looks like thisSome position their pelvis too far forward, tilted forward. Then they arch their back to get into an upright position. Most people have been taught this ‘pelvis-forward’ position is good posture.  

In fact, although no longer available, years ago I developed a posture App. In the first step I would tell users to maintain this pelvis-forward position. In a video accompanying the App I would explain that in this position your mid-back would get very sore after a few hours and that this was normal. Years later, I can tell you this is not normal.

I actually began to have back pain because of my will power and belief that I could eventually maintain this position all day.

It is reasonably embarrassing to be a published author on back pain and one of the world’s experts on back pain and to actually have back pain. This is NOT a correct position. The pelvis is too far forward.

Pelvis Tilted Backward

Dr Sean Wheeler Posture Pelvis BackwardModel demonstrates pelvis backwardThe next mistake is what is referred to as pelvis posterior [tilted backward]. With your pelvis in this position it is impossible to get your head over your shoulders.

People usually go back and forth between each of these two positions; pelvis tilted forward vs. tilted backward. Maintain one position until they get tired and then go to the other. Some people will spend their day standing with their pelvis forward and sit with their pelvis tilted backward.

Correct Pelvis Position

The correct position is somewhere in the middle. At this point, people will often attempt to roll their pelvis into a middle position. Unfortunately it is not that simple.

If you choose to just roll your pelvis, you will be able to get to good posture, but only when you are sitting.

Standing with your pelvis in the correct position requires bracing muscle strength, and hamstring and hip flexor muscle flexibility.

Improving Pelvic Position For Good Posture

As described in my book UPRISE: Back Pain Liberation, by Tuning Your Body Guitar, bracing muscles are the muscles that brace and stabilize you so you can move. But improving pelvic position can be a nice start on the whole process.

Sometimes people are so tight they can’t move, or so pelvic unaware that they need exercises to loosen and become aware of pelvic position. This is best done in the hands of a physical therapist, but often your personal trainer, yoga or Pilates instructor can show you.

How To Do It

Start by standing. Then draw your tummy in slowly so that your pelvis rotates under you until you feel like you can stand up straight with no strain in your neck and a small arch in your back without tension in your mid-back. It is very important that you use the muscles in your tummy to move your pelvis into the correct position. It is also important that you are not clenching your abdominal muscles tightly, but gently drawing them in so that your tummy is somewhat flat.

Congratulations! Now hold it all day.

Warning: it will take you six months to build the endurance to be able to do this all day. These bracing muscles need to build the endurance to hold you in this position for many hours. Much like preparing for an endurance race like a marathon, this doesn’t happen in 6 days or 6 weeks. It takes 6 months. You have to build blood flow to muscles to get endurance. Circulation training. But it is worth it.

Correct pelvic position will change your posture and correct posture will change your life. A 180 degree turn in your life — for the better — in 180 days.

Seek Out A Professional To Assist

These concepts and instruction can be difficult to understand just reading an article or seeing pictures.

You really must have a professional put their hands on you and show you where your pelvis should be. Where you are weak, where you are tight and what you need to work on to obtain the goals you seek. As with most things worth doing, it is not easy and requires a commitment.

But unlike ‘just sit up straight,’ this advice will actually work.


Sean Wheeler, M.D. is board certified in both Pain Management and Sports Medicine. He is a leading expert on back pain and his recently released book UPRISE is changing the way the world approaches back pain. With a new vocabulary and new medical approach, Dr. Wheeler puts patients back in charge of their health to achieve liberation from chronic back pain. His middle son, Sammy, is a little pensive about having his shirtless photos spread across the world wide web.

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Your body is a finely tuned instrument. Like all finely tuned instruments, it must be properly cared for in order to play the beautiful music it was intended to play. Care for your body and use it correctly, and it will play music that is unique to you – your life song.

– Sean M. Wheeler, M.D.

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