The Empowered Beyond Pain Podcast

Episode 16a

Posture and Pain: Low back pain fact 6 with Diane Slater and Dr Kieran O’Sullivan PhD

Low back pain is still the world’s most disabling health condition and costs more than cancer and diabetes combined. A scientific journal article covering 10 facts about low back pain was recently published in the British Journal of Sports Medicine ( The origins and motivations for that paper, as well as patient stories, were covered in episodes 4 and 5 of the podcast. In this episode, Professor Peter O’Sullivan welcomes Diane Slater and Dr Kieran O’Sullivan. Together, they discuss low back pain fact number 6: Posture does not cause back pain.

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Episode Show Notes:

O’Sullivan PBCaneiro JO’Sullivan K, et al
Back to basics: 10 facts every person should know about back pain

The posture and pain infographic discussed in the podcast:

From this paper: 
Slater D, Korakakis V, O’Sullivan P, Nolan D, O’Sullivan K. “Sit Up Straight”: Time to Re-evaluate. J Orthop Sports Phys Ther. 2019 Aug;49(8):562-564. doi: 10.2519/jospt.2019.0610. PMID: 31366294.
Other Supporting references:
O’Sullivan, Peter B., PhD*; Dankaerts, Wim, PhD*†; Burnett, Angus F., PhD*; Farrell, Garreth T., M Manip Ther*; Jefford, Evonne, M Manip Ther*; Naylor, Clare S., M Manip Ther*; O’Sullivan, Kieran J., M Manip Ther* Effect of Different Upright Sitting Postures on Spinal-Pelvic Curvature and Trunk Muscle Activation in a Pain-Free Population, Spine: September 1, 2006 – Volume 31 – Issue 19 – p E707-E712 doi: 10.1097/01.brs.0000234735.98075.50

Peter B O’Sullivan, J P Caneiro, Mary O’Keeffe, Anne Smith, Wim Dankaerts, Kjartan Fersum, Kieran O’Sullivan, Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain, Physical Therapy, Volume 98, Issue 5, May 2018, Pages 408–423,

Richards KV, Beales DJ, Smith AJ, O’Sullivan PB, Straker LM. Neck Posture clusters and their association with biopsychosocial factors and neck pain in australian adolescents. Physical Therapy. 2016;96(10):1576-87. doi: 10.2522/ptj.20150660.

Dankaerts W, O’Sullivan P, Burnett A, Straker L. Differences in sitting postures are associated with nonspecific chronic low back pain disorders when patients are subclassified. Spine (Phila Pa 1976). 2006 Mar 15;31(6):698-704. doi: 10.1097/01.brs.0000202532.76925.d2. PMID: 16540876.

Dankaerts W, O’Sullivan P, Burnett A, Straker L, Davey P, Gupta R. Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model. Spine (Phila Pa 1976). 2009 Jul 1;34(15):1610-8. doi: 10.1097/BRS.0b013e3181aa6175. PMID: 19564772.

Wernli, KO’Sullivan, PSmith, ACampbell, AKent, PMovement, posture and low back pain. How do they relate? A replicated single‐case design in 12 people with persistent, disabling low back painEur J Pain2020241831– 1849


posture seems to be mentioned um in certain categories you have a category where people are wanting to talk about posture because they are worried about protecting their spine they say well i know that i need to sit up straight so i know that that shows that i’m strong or i know that i have to pull my my muscles on whilst i’m sitting whilst i’m doing these exercises and so yeah they’re just they’re just really in back to me the things that they think are common knowledge and that they they certainly are surprised when perhaps by i maybe take them down a journey of discussing where those beliefs came from and whether we understand the research behind those beliefs welcome back to another episode of the empowered beyond pain podcast proudly brought to you by body logic physiotherapy in this podcast we bring evidence to your eardrums to help translate research knowledge into real life this week we have another cracker episode covering all things posture and pain so get ready sit up straight or wait no maybe that might not actually be that important either for preventing or treating back and neck pain as you hear in this conversation there are many widespread misconceptions when it comes to posture sit up straight don’t slouch don’t round your back these are all beliefs that i myself and the guests on today’s podcast also used to hold it wasn’t until we started researching posture and pain that we started to realize that those beliefs might not be that accurate or helpful so sit comfortably which may be different to someone else’s comfortably and enjoy the conversation we initially had planned on only one episode on this topic but because it’s such a big topic and we spoke to a variety of different researchers as well as a patient voice we decided to split it into two episodes an a and a b this week professor peter o’sullivan and i chat to diane slater and kieran o’sullivan who have both recently been working and researching at the asphata sports spine center in qatar we talk about posture myths facts posture correctors and a research paper that diane led conveying seven surprising facts about posture we created an infographic for that paper which can be found as well as the supporting references from the studies discussed today at forward slash podcast in the next episode posture part b we’re speaking to patient voice joe from episode 14 again as well as to nick saracini a physiotherapist and phd researcher from curtin university whose entire project is on lifting posture and back pain we’ll kick off today’s episode by hearing fact 6 from the 10 facts every person should know about back pain scientific paper presented by patient voice michelle back pain is not caused by her posture how we sit stand and bend has not been shown to cause backpack even though these activities may be painful a variety of postures are healthy for the back and it’s safe to relax during everyday tasks such as sitting bending and lifting with a round back in fact it can be more efficient thanks for your continued support and kind words a chiropractor from finland said he can’t recommend the podcast enough he especially loves episode 11 and thinks all healthcare professionals should listen thanks berto sharing the podcast with your networks is the best way you can help make this information common knowledge so please share away and tag us at ebp podcast on the socials and together we can make contemporary pain knowledge go viral but for now keep on asking is there more to pain than damage [Music] welcome to the podcast guys we’re very lucky to have well three researchers and clinicians that work with working this low back pain space and particularly we’re interested today in the posture story so we’re joined here with diane slater and kieran o’sullivan who isn’t related to peter o’sullivan um but you know not that we know of but they’re big names in themselves and we could probably have a podcast episode with themselves and maybe we will in the future but i’d love for you just to quickly introduce yourselves and who you are and what you do maybe we’ll start with you diane hi thanks for having me so i’ve been working with kieran um at the time the sports spine center and that’s how we started to um to work together my background is um as a sports physiotherapist working with lots of different team sports and individual sports and then i’ve also did some work with the british military as a civilian not as a member of the military and um suggest a very general msk physiotherapy background awesome and kieran so um i trained as a physiotherapist in ireland and uh worked in clinical practice and over the years i developed an interesting back pain partly as a physio but partly because i had quite a bit of back pain myself and with hindsight managed to make lots of mistakes in terms of you know what i was trying to do to help that and one of the things i spent a lot of time thinking about was the way i sat and the way i bent and how i activated my postural muscles um and over time i guess through working with people like peter and reading some of the evidence i’ve come to look at that quite differently um like that i worked with dan for a couple years in the middle east and now after topping up my bronze irish complexion i’m back in the sunny southwest of ireland yeah cool and maybe we’ll explore that kind of lived experience in that history of that posture research uh a little bit in the podcast today i’d love to start with so you you two and um peter as well were involved in a viewpoint in the jospt um titled sit up straight time to reevaluate um diane you led that paper and and hearing you with their senior author on that diane what were the motivations for that for that paper as a clinician talking to patients about posture i was surprised really that the the conversation wasn’t really changing over the years so the way that i would um perhaps offer advice had changed like following the the literature that was coming out and i certainly have evolved an awful lot as a physiotherapist going from being a very much a manual therapist and giving postural advice in the past about sitting up straight and then but the conversations that the patients were were directing um me to have with them was much more around these beliefs that the beliefs seemed quite stubborn um and didn’t seem to be changing with um with perhaps the viewpoint that all of us in this conversation maybe now have and i wanted to sort of explore a little bit about why those beliefs of the patients weren’t changing and and maybe what was happening in the wider profession as well so so what are some of the common beliefs that patients come with us that maybe aren’t as evidence-based or as contemporary as as they perhaps should be from my experience posture seems to be mentioned um in certain categories you have a category where people are wanting to talk about posture because they’re worried about protecting their spine so they think that they have this particular way that they must see um in order to keep themselves safe and actually when people start to talk about it with me they seem to mention it in a way of course i’m going to agree like they’ll say of course my posture is bad and of course my postures you know i know it should be better but and they’re coming at it from an angle of safety and protecting their spine i think another group of people tend to talk about posture beliefs around the the image that it presents to other people and they’re not so concerned about the safety side of this and maybe their beliefs are much more around their body image as opposed to around the um the protection of the spine so this idea that they’re sort of being lazy or they’re not um you know engaged or attentive yes yes and they will often feed back you know things that they’ve heard whether it’s in the media or from other healthcare professions all from the exercise professions um the way they say well i know that i need to sit up straight or i know that that shows that i’m strong or i know that i have to pull my my core muscles on while something you know whilst i’m doing these exercises and so yeah they’re just they’re just relaying back to me the things that they think are common knowledge and that they they certainly are surprised when perhaps i i maybe take them down a journey of discussing where those beliefs came from and whether we understand the research behind those beliefs so can you talk about the research behind those beliefs i think um you know the it’s such a such a common thing and people are often quite sort of astounded when we’re we kind of talk about you know it’s it’s okay to slouch if that’s more comfortable for you and you don’t need to maintain this you know quite unquote perfect posture all the time um so you know they’re often quite surprising things so what what does the research tell us around around posture and is there such thing as a correct posture the research is quite surprising and i remember as a certainly the more junior physio definitely um you know telling people that i believe that there was a correct way to fit or a correct way to hold our posture but i think perhaps um kieran and pete would be best placed to discuss their their journey through the the foster research because certainly they’ve been been around and evolving a bit longer than i have yeah sure absolutely um i’d um i’d like to ask dan what she means by saying that i’ve been around a lot [Laughter] in the past this caroline is is kind of um it’s not healthy this is a toupee peter peter is like uh president trump he insists that that’s his own hair yeah but i don’t claim tax on my hair products that’s true um i guess they’re looking at some of the um i suppose we can we won’t get into all the weeds over around what the research does see i think interestingly what the research my reading of a lot of the research on posture is isn’t so much that it says it’s unimportant it’s that we’re emphasizing stuff this stuff that we can’t say with any consequence because for any tissue you know there is going to be an an um an importance of how it’s loaded so if you’re going to look at you know um stress fractures and achilles tendon up but there any musculoskeletal complaint the way it’s loaded might be important but we start we started off with a perspective that there is one right way or one safe and appropriate way to load it now um of course there will always be extremes but what the evidence has said very consistently over the years is that the beliefs we used to have around deportment and posture aren’t really um supported in terms of preventing or managing musculoskeletal pain and historically a lot of it is based around um you know attitudes around what was um you know um i suppose beautiful or graceful or you know aesthetically pleasing and almost to do with you know being a suitably intellectual middle-class person as opposed to somebody that might be seen as a manual laborer and you know less socially desirable um one of the things i’ve noticed is that as soon as especially if i’m giving a talk to members of the public in rome if as soon as i kind of introduced that you know maybe i’ve done my phd on posture and back pain or if i tell them i’m going to look at posture almost without exception everybody in their own will change the way they sit and assume a more upright posture and that in itself just demonstrates how we have these perspectives around what’s good posture now again i sometimes get asked by people like would you ever suggest to somebody to sit up straight and the only examples i can come up with is that if you’re going into an interview sitting up straight is not going to help your back pain and i don’t know that it will help your job in any way but unfortunately we have certain stereotypes around what is what it means to be interested and you know a hard-working person so if even though i’m somebody who says habitually slumps and i’m quite comfortably with comfortable with it i think if i was going in for an important interview i would almost feel pressured to sit upright and uh because that projects an image of being interested but again unfortunately they’ve all become mixed together that if you want to be beautiful especially as a woman you must sit upright if you want to prevent back pain you must sit upright if you want to look like an eager beaver worker you must sit upright and they’re all quite different things so it’s not that we’re saying posture is irrelevant but in the narrow frame or lanes that we’re looking at in terms of does make you less likely to get pain not at all and there are probably much more important things to look at in terms of beyond posture and then if we are going to look at posture we might want to think about well what do we do to support the knee and the shoulder and in those parts of the body it’s never around rigidity and keeping it tense it’s around making it strong and having shock absorption and mobility and so on so while we’re on the topic of if there’s more important things than posture do you want to just quickly talk about um some of that sort of stuff just to give a bit of a more of a i guess a rounded um finish to that that answer yeah cool so if we talk about it’ll be the same aspects but an awful lot of the people we see with persistent pain it won’t be triggered by you know an individual postural incident and so there’s a whole series of things from you know psychological things like mood and anxiety and stress and social things such as what’s going on in your life in your work pressures and family situation lifestyle things such as your sleep and your activity patterns and and varying combinations of these you don’t even if you look at the pandemic we’re living through it’s caused huge changes in people’s lives some of those beneficial maybe less commuting time work life balance pressures but again it’s varied a lot uh unfortunately the way we’ve kind of um developed uh our view of back pain is that yeah i’ve seen this even in the media there’s been a load of advice in the media in ireland around now that you’re working from home here’s what you need to do to prevent back pain and it’s around make sure you have a desk and a chair that’s appropriate and a mouse rather than working on the you know they are sorry um rather than working on the keypad and others and all those things may have a place it doesn’t look like it’s very important and these articles almost never focus on well what does um the fact that you might have been homeschooling your kids while trying to hold down a job and work from home and work remotely and for me if you’re going to say to me from that period from say march to june for example in ireland when it was there was a bit of work required in homeschooling and and all that kind of stuff and you gave me the choice of which would you prefer would you prefer a mouse uh to kind of reduce your risk of straining your wrist or somebody that can mind your kids for three hours so you can have uninterrupted work i have no doubt in my mind which would be more beneficial for my musculoskeletal system yeah sure let’s kind of speak into that whole multifactorial multifactorial i suppose experience of pain and the factors that contribute to it now i i think you’ve also had you sort of touched on that you had a bit of a personal experience with with some back pain and some posture beliefs can you talk us through those a little yeah sure like um i suppose you could you to make the story short i guess like a lot of people who played sport i developed some aches and pains um and both of them in different ways probably reflect you know how you can have a muscular skill complaint and then for it to be handled so optimally so as a teenager i developed your current shoulders location which i eventually ended up having surgery for the surgery was quite successful in that it stopped dislocating yet i developed and had persistent um apprehension around this for quite a long period of time and that protective response on my shoulder um took far too long to drop which probably reflected my own anxiety and my own sense of protection um and even though other people were you know aware of that it was something that i struggled to um kind of get on top of but i did go back eventually playing sport but that was almost where you could say there was an orthopedic trauma you know related to physical trauma and and some psychological factors that were connected to that but then separately to that a couple years later i developed quite a bit of back pain and it had a big impact on my ability to play sport which was a big part of my identity and what i was known for and then because it was probably kind of resistant or current and didn’t fit any particular model um i spent a lot of time seeking help and support from it and at that time a lot of the advice would have been on one hand about the dangers of um flexing and and the importance of protecting the back and then equally the desire to keep playing sports so i ended up kind of jumping between i kept irritating the two playing sport and yet wasn’t really able to understand all the different things that were going on in my life and with the benefit of hindsight and all this that i can now see that it happened at a period of time where you know i was doing my work as a physio where i wasn’t really loving it because again i didn’t really understand i think what we were doing unlike a lot of the guys i played with i hadn’t progressed to the highest level of sport so my self-esteem and my confidence and my kind of sense of who i was was definitely challenged by all that and um you know there was just those same mix of factors we see in lots of people the sense of not being in control of your pain and the unpredictable nature of the thing and it was fact only after kind of working with people like peter and gradually first of all understanding pain and also just getting to a better position in my life where sport wasn’t as important that you know the pain settled quite a bit um and you know hindsight is everything uh but i do think we will still see a lot of people where they’ll be in that situation where me like a lot of people back then my pain was treated uh by me and by others as a an injury a tissue injury now of course there was no susceptible input probably but the broader context of about what the pain meant to me and what i was doing to do it was probably a much bigger part of it than i would have been aware of at that time and being honest i think if somebody had approached me you know saying that at the time i would probably have resisted it because for me back then even though i was a physio and i’d heard about these biopsychosocial things i probably had the perspective that that was for people who were pretending they weren’t you know didn’t want to get better or that maybe had really severe psychosocial factors where they were suicidal or so depressed that they were lying in middle whereas i think there’s a large chunk of the population where their health of their life isn’t optimum and that just drags down their hope overall yeah sure thank you for sharing that i think that’s a really relatable story as well um and and you know hindsight is 20 20 and i think you know we we’re we’re all um you know there was a period of time where i would tell people and and correct people on their posture and um you know knowing the research and going through that journey it’s it’s kind of evolved now and and i think it’s probably um you know that’s a nice segue into where some of the research into the posture started that yourself and pete were involved in you know the the messages that we used to give or that we the research findings used to um talk about or used to yeah reveal uh are different to what they are now so um maybe pete yourself and kieran can talk a little bit about the journey of how research has has evolved well it’s interesting you say that kid because my first thought about posture i think the first time i really thought about posture it wasn’t discussed in my home i don’t think at all as as a kid i don’t think i ever had any attention on my posture at all my first day of physiotherapy school we were all stripped and i was like a pretty shy 18 year old left home and i was stripped of my underwear in front of this group about 46 mainly women and i was pretty skinny and not you know like probably a little bit underdeveloped at that stage and and then we had photographs taken of our of ourselves and mine was a side and side on photograph and i was told what terrible posture my heads so that was my first introduction uh to my physiotherapy training in new zealand and dunedin and and i think that kind of seeded this whole belief and was certainly a big part of uh the training back then around the importance of posture and that kind of was partly linked in too with a lot of the mckenzie approach back then that kind of created this horror story of the vulnerability of the disc if you’re slouched or if you’re bent or if you had a round back or you sustain that for a period of time you put this disc at risk and you know the nucleus pulposus would pop out the back and you could rupture your disc and so there was this kind of catastrophic belief that was embedded around that time around posture and so you know this idea that you need a lumbar role and you sit and you have to keep the curvature and all that stuff was really powerfully embedded and kind of wrapped in this um quite frightening time structural model of understanding pain and and i remember um coming to western australia to do my post graduate i i must admit as a clinician it puzzled me because i’d see these patients who’d come in who would go you know can you bend over go no i don’t do that anymore what it’s like you know because that’s dangerous for me so you could see how these messages create a lot of fear in people um and then that kind of um some of glass tubey’s early work had really questioned a lot of that pathological model around the whole disc story that was embedded in the mckenzie approach and so it kind of created some of these seeds of doubt um and it also at that time you know in that early you know they were early 90s um to mid 90s when i was involved in early research we were looking at emg studies of people with pain and realize actually their muscles were really overactive and um they weren’t you know we had this picture of you know the back being with pain being vulnerable and unstable and you need to just stabilize it with the core and your multifidus and your abdominal wall holding these neutral spine postures and we’re seeing these patients who are coming in where they couldn’t switch the bloody muscles off where the the postures were really rigid and guarded and and it kind of created this question mark around what was going on with posture and that kind of morphed into a whole series of posture studies both at a population level some are women duncan’s early research looking at people with back pain and then people without back pain and seeing that actually there’s a variety of ways that people with pain hold themselves um and and i think the issue the reason why it’s so interesting for back pain is it is one of the most disabling things for people with back pain we often presume that people are back pain have problems with activities but actually sitting and standing are really commonly disabled disabling things for people so they are massive sources of disability and i certainly have seen patients who literally won’t sit down or people who’ve had a panic attack with the with attempts to sit down about being so disabled or people who literally wouldn’t stand for any period of time and you know i’ve got a case at the moment who would be hot you know almost develop an anxiety response just standing in one position um and so it’s kind of interesting when you start looking at human responses or people’s behavioral responses to pain is that we’ve almost created i think a fear around the spine in posture and this whole narrative that we’ve created i think it’s become incredibly unhelpful uh and is embedded in this disability i think um that is linked to it and certainly the the research studies show that people when they with back pain when they sit don’t sit relaxed uh they might sit in a variety of positions but often if particularly if they’re really in pain they’re very guarded and protective around their posture and that probably fits in with some of these things that um that we’ve seen and and certainly if i throw that back to you karen um with your phd you looked quite a lot at posture uh in a few different groups and i wonder if you want to talk about some of your findings and that’s in those studies yeah cool um the thing that comes to mind when you’re talking about that their heat is that um they’re great value to seeing patients and working as a researcher and i think it you know it leads to better research questions and and there’s many advantages the one disadvantage i would feel when i look back in terms of my work when i was working as a clinician seeing patients working on their posture what i used to see you know in my kind of a subjective sense was that i would have some people who were low-risk mild pain and i would give them exceptionally complicated posture and core exercises but you know what they would do well so that confirmed my beliefs that that’s what was key and then i would see these other people who were very distressed had a really tough time really suffering and i would give them the same exercises but which of course were very complicated they didn’t feel they had control over they’ve made them feel bad and then they would come in and i would lecture them on how bad they were or you know a variation of that and then they would do poorly but in my lens it was well the people who complied with my overly complicated exercises did well and the people who didn’t didn’t do well and it’s only when you step out of some of that you know the clinical stuff is great but it’s only when you step out of that and you look at some of the trials and peter mentioned the big population studies like the rain study done by peter and leon and those people when you step back and look at the numbers or even some of the other big population studies it’s very hard when to say that you know we’re going down the right track with some of that very very specific postural stuff and that’s what i saw in some of my own phd work um what i what i think at the pa my own phd work will say what it did show me is that that doesn’t mean postures irrelevant completely so we saw same as with wim dankers we saw some people where their pain is provoked by the way they move and there are some characteristic ways of holding yourself you can talk about different ways of doing it where people unnecessarily and unhopefully provoke their pain and so even though we’re all here saying you know posture is not what we were meant to believe if you’re pain free you should probably just not give it too much thought but if you’re in pain it might be worth spending time just thinking about how you hold yourself and and we looked at a few things looking how people bend and using there was a couple of different ways using some postural biofeedback to see can we help them to move a bit better or even another work with some students looking at how people sit on chairs and we found for example that if you take things like saddle chairs where you’re propped up and it makes you sit a bit more upright um on average it makes no difference but there will be people who feel much better on it and people who feel much worse in it and so rather than having fixed ideas about this is what makes good posture listen to the person see what they’re thinking about the rack see if there’s ways they can feel more comfortable and so i don’t go around recommending that you must try a lumber roll or you must try this chair but if somebody has a lumber roll and they’re not a bit bothered by it that’s fine you know we’re not going to be there are bigger battles that we’ll face um and i think that’s probably i was probably slower to kind of appreciate some of those factors than somebody like peter for example in terms of teasing out when it’s worth looking at some technical um stuff and and moving stuff and when it isn’t and i think that’s where some of that research done by probably other groups in terms of pain mechanisms has been useful so like if this really does sound like a tissue strain tissue injury and it’s you know aggravated and eased in a very predictable manner well then it might be okay to spend some time looking at your technique and all the rest of it and those people do exist but they are not the ones clogging the emergency departments and on long-term sick leave as far as i can see and so for those people we need to look at other strategies and part of that if we look at some of the stuff that’s been done on behavioral experiments can be useful in terms of it’s a very powerful learning experience um to show somebody how to move or sit or bend in a way that’s less painful because but that requires some physical technical skills as a physio but also a great ability to reassure people and make them feel confident yeah yeah cool thanks for that that’s uh that was really nice nicely described i want to kind of bring it back to some practical advice just for the general population you know we have listeners that are people in pain people that don’t have pain um you know physiotherapists and other health professionals as well uh what what should we be advising people um you know in terms of their posture thank you take that ball um i think i think to be hearing kieran’s points there that one size doesn’t fit all um that we’re not going to say that the the posture isn’t um relevant that for some people obviously it is i think the main points that i find myself repeating or repeatedly saying to patients is more around um but like are you comfortable in the way that you are sitting so just you know it helps them to reflect on their own beliefs a little bit as well and not because often they’ll say well actually you know i’m more comfortable when i sit slouched but i’ve been told i shouldn’t do that and so just just getting people to reflect on on what their experience is in different positions and i think when people first of all just pay um attention or have a bit more awareness around how they’re doing something it allows them the opportunity to to reflect and perhaps to try and experiment with some different movements in different positions so often what i find is people don’t realize that they’re always adopting a particular position so that might be the way that i talk to them about posture so so i think helping people to to just to break to to have an awareness we don’t want them to become overly focused on on how they’re sitting but have an awareness instead of say well okay what feels more relaxed i think if there’s one message that i would be sort of sending out um generally it would be about about being relaxed and and just what feels comfortable to them rather than any hard and fast rules yeah yeah sure that’s right the um the thoughts that come to mind when i think about like the advice we give people this partly is based on i suppose some of the challenges we’ve faced before it’s tricky to um we produced an infographic related to this paper and while in one sense they’re useful if sometimes people just see a heading if something is so contradictory to their beliefs it can be easier for them to dismiss it and so one of the challenges one of the bits of feedback i’ve got which i’m not sure how we change is that there will be a lot of people out there who get pain bending forward and when you see them in the clinic the pain bending forward is likely related to the fact that they don’t flex their back at all and they keep it bold upright and so they move very rigidly and it’s very sore however in their head what’s happening is they’re getting pain from flexing too much so their strategy is to be more and more and more careful and when i say things to them or when they’re reading a leaflet bending is not dangerous that makes no sense to them because their experience of bending is very very tricky and it’s i don’t know how we come up with a a paper-based infographic or paper that illustrates that now there’s probably ways in which if you had a nice animated video or actual video of showing different ways of doing it you might be able to explain that but there are you know as a society i think we conflate flexion and bending and treat them as if they’re the same thing and they and they almost certainly aren’t can i i don’t answer that sorry sorry just to add on to that so similar to with the sitting so and people who sort of say well i have pain when i’m sitting so then if it’s that relationship between pain and danger or whether if they’re experiencing the pain then the physician must be dangerous and i think just to explore because not just the just the belief about the flexion but also what the pain means and um and just asking patients about where this threat comes from what like how is fitting dangerous and and just allowing them to sort of just to explore that themselves i said well if i’m sat here and i’m not moving but i have pain what does that actually mean and and a lot of it’s around their understanding of what the meaning of pain is yeah absolutely and i guess one of the things i’ve touched on with dan before dan’s worked in the military for quite a while and you know being upright in the military that’s actually you know almost an essential component and it’s probably something worth teasing out but one of the things i’ve tried to do with patients or in terms of talks is to kind of almost confront people at the start when they say what’s the right way to say to go back to that point of view for what is this to look good in address to look impressive in an interview to look attractive because that might require one approach but if you’re asking me about pain that’s a different thing altogether because you know it’s it’s i had a musician at one point who um had a lot of pain and was very strongly connected to stress anxiety but also a very very upright posture and i asked her to explore sitting in what i felt was a more relaxed position and when i asked her how she felt that was she’s the word she used was i think it’s disrespectful and lazy you know and so like people’s views of what a posture kind of says about them is important to be aware of as well because i could have told her that’s a good position or a stretch but she was never going to engage with that if she felt that’s how it was viewed by other people i think yeah i think the one thing i’d pick up on that too karen is um that what people perceive they look like and what they look like are different and that’s why taking of having a mirror or taking a photograph is can be such an important thing because they perceive that you know being slightly relaxed is being like a banana uh we’re actual fact they’ve just gone from a you know an over exaggerated upright position to a relaxed neutral position but in their mind they perceive something quite different and so we know that when when there is pain and anxiety people’s perception of their body can be quite distorted uh and so we have to be very careful around you know presuming one thing it may be that it that for say for a dancer then a more relaxed posture actually isn’t that you know something that would be recommended um by the co by the you know dance instructor or whatever but in other in other situations i’ve seen very frequently where people’s perception of their body is different to what they actually look like and so there’s that whole element that does come into it too it’s a good point because you know in my mind i look like a pale balding middle-aged wrinkly irishmen but obviously it’s nothing could be further from the truth that’s true i’ve asked for that with the military um when when the guys are on parade and obviously that would be a big thing that they would need to be to be stood in a particular position and often a piece of point about just getting them to relax and they think well no i can’t stand like that i would get i know i’d be called out for that but if you just talk about them just let just letting go of their breath just really relaxing their stomach they feel that they look really slouched and again if you show them the photo actually they they realize that no no i wouldn’t i wouldn’t stand out from the rest of the guys on parade if i’m doing this and it is just that different difference and perception yeah and and i think the other thing that’s worth touching on and this fits in with some of the um data in your recent paper kev is that a lot of the patients that we do see who have quite distressing back pain a bit like the lifting story where people when they have pain start thinking more about their posture i think and and then they start holding postures that they think they should hold because the reason they got back pain was their posture was so terrible and now that we’ve got it they’ve got to try and prevent it getting worse by holding it very upright so those powerful beliefs start kicking in and and so often you know what we see with a lot of these patients is they hold very tense and very upright postures that are actually quite uncomfortable and you know they’re not dangerous in themselves but to hold we kind of use the analogy of clenching your fist if you do if you’re right if you’re writing a letter to someone and if you over clench your the pen you start getting right as cram and you have to stop you know there’s nothing dangerous with clenching the pan when you’re writing a letter but actually your ability to perform that task over a long period of time can be quite painful but you’re not damaging your wrist or your arm in the long run but in the same way if you’re adopting that with around your posture of your body that you’re holding these um rigid or guarded postures for a long period of time they can be quite painful not dangerous but very uncomfortable and fatiguing and and if the system is sensitive then that could be provocative their pain and that’s where you know working with a healthcare practitioner to not just work within a posture paradigm but actually explore the patient’s experience amongst all those other factors uh is i think very important and certainly in your um in your case series kev that was what you observed i think yeah absolutely and i think you know just touching on that point as well you know tense muscles can hurt after a while you tend to muscle for a long period of time and it’ll start hurting but yeah certainly a large percentage of the patients in all the participants in in my case series would hold these postures they’d be quite upright they’d sit tall they’d pull their shoulders back they’d be bracing through their core and and ironically that’s what that we know as good posture but then as as as they got better as they improved their postures actually returned to more kind of quite unquote normal or more relaxed more slouched um positions that was both in sitting and standing um so yeah we can kind of see how these beliefs can really um drive people into into places that that are not good not nice one of the one of the challenges i think for people like us because you know we’re in our little um bubble where we all agree with each other one of the challenges i think is to if we convince people that this with this message that you know some of those outdated ideas about posture you don’t need to worry too much about them there’s a risk then that we get seen as saying that mechanical loading is irrelevant and of course that’s not what we’re saying but i’m sometimes struggling with how do you get across that again in a in an infographic or a short media interview because you know when you go into an occupational setting we can deconstruct some of the postural beliefs but then if you have the control you can also say now if you’re going to do anything about mechanical load of your back don’t worry so much about the angle but just look at the volume and the magnitude of loading so if you’ve gone from doing nothing and now you’re going to be doing this physical loading can we build up your conditioning to be ready you know to do that and so but i’m not sure how we get that message across you know in a in the kind of the world we live in where it’s a short snapshot infographic or animated video that we get across because we do want people like with the work that nick and dave nolan and those are doing to reduce some of the fears and the and the outdated notions about posture but also to understand that same as if you look at hamstring injuries or any tissue kind of condition building up load tolerance is important but unfortunately in all the ergonomic manual handling advice that i’ve seen it’s well avoid all that load and be very careful yeah and then hope for the best whereas what we’re actually saying is well don’t worry too much about that but build yourself up and prepare for it but that’s a bit nuanced to try and get across any any simple hitting and i suppose around that we really need more research to see whether a different narrative has an effect an impact because we know that the ergonomic interventions haven’t haven’t really had any influence positive influence on pain so we really are waiting for um a different narrative to test whether we can have you know a positive impact because we know from a prevention point of view it’s actually very difficult to present prevent back pain there is some evidence around engaging in regular physical activity as being preventative or protect around pain episodes but actually as you said there’s probably a much broader story around you know people’s risk of of back pain and particularly disabling back pain uh being linked to a variety of factors around their general health and their sleep and their physical activity and their how sedentary they are and all of those things which is just a bigger story um which i think needs to be told but it’s a harder sell yeah because it’s i don’t think we’ll say you can you can take what we’re saying and say that we want there to be no occupational health departments we probably want them to focus on different things because if you look at the whole area of sick leave and having a middle man or middle person you know liaising between the employer and the staff member it’s important that somebody knows the context knows the environment but just changing the narrative there from the dangers of work to the opportunities work brings and how do we make sure you’re able for it in a graduated manner and it’s almost like a um a health message rather than a um than a it’s as like a health a model of health rather than a model of sickness i think which is kind of like we’ve kind of created this model of danger and injury rather than saying what’s a model of health look like and how do we optimize that and and you know we we of course are talking about it in our own kind of a physio msk bubble but even if you look at the pandemic we’ve seen some of those same complicating factors in terms of asking people to avoid certain situations but then they work in a situation where they won’t get sick pay if they don’t go to work so you know if we really want to change behaviors we have to make we have to stop penalizing people for getting better so if i have somebody with back pain and i think it would be good for them to go back to part-time work then they shouldn’t in a court or a medical insurance um system be penalized for getting better and they’re all they’re all part of that message as well yeah awesome i want to bring it back finally to the the paper and then ask one final question of us of you guys and i just thought i’d quickly go through the infographic that we developed in terms of the the seven facts now this will be available in the show notes page but i just want to quickly rattle through them so people have an idea of what they are number one is there’s no single correct posture two is differences in postures are a fact of life and we’ve discussed lots of these uh in in the chat today three posture reflects beliefs and mood four it’s safe to adopt more comfortable postures five the spine is robust and can be trusted six sitting isn’t dangerous and seven one size does not fit all um we’ve touched on a lot of stuff today which is which is fantastic now one of the most common things that comes up you know in people’s news feeds on online and for you know the recommended posts and sponsored ads are posture correctors so what’s the go with them so there’s a lot of marketing around these and some of them will be now more sophisticated than high-tech sensors and gyroscopes and so on again uh look some of them have a business model and the business model is on selling lots of units if you’re going to say what’s the evidence then any of them would prevent musculoskeletal pain the original there is a separate argument as to whether we should even try to prevent msk pain at all you know like some of this stuff is just normal aches and pains um for me right now i would take a lot of convincing uh before i would be suggesting to any patient here is this device and now you go and do it now the the real i suppose the best possible kind of change that narrative would be on the restore trial and peter can talk to that where there’s a specific you know validated instrument that’s been used as a form of feedback but right now when it comes to the facebook ads and all the rest of it i think there’s lots of other things we could get the basic building blocks in place in terms of mobility thoughts work life balance sleep physical activity um and any of those other adjuncts right now would be well down the track but again i’m open to be convinced by good data and we’ll have some of that from a store in 12 months or so so look we should have some of that information yeah 12 to 18 months we will have an idea whether providing feedback around the body uh actually enhances outcomes or not from our trial so that’ll be really interesting um you know from a personal position um i personally don’t use any of any devices when i work with patients and and my my i suppose one of my concerns is that it creates a focus for the therapist and the patient around one dimension of the problem and not on the biggest the biggest story of pain and and i think for a skilled practitioner maybe that you could like that may be okay but i think there’s just this greater extent i think from my perspective um i’m happy when people don’t have to think about their back and i think this constant attention to the back creates a sort of vigilance or hyper focus which in many cases could be quite unhelpful um when do i say to people when’s your last thing about your elbow and they go what like yeah so like how much do you think about your back all the time what do you think about all my posture and what i’m doing when did you last think about your elbow well i don’t is it a problem but if you had tennis elbow and you and it’s really sensitized all you can think about is your elbow now of course sticking a you know a couple of sensors on your arm to look at where your elbows going you know would that be helpful so this idea of putting lots of attention on the body part that’s in that maybe have pain uh may not be in fact so helpful but we’ll have a lot more evidence around that from within our study and you know that’s why we do research is to explore these things so that we can you know not just have our own opinion but actually have some good evidence to um to give us an idea and it may be that for some people they could respond really well to that and others it might really piss them off or may not be helpful and we’ll have some idea of that as well yeah that’s cool yeah but certainly speaks a lot of about um living in the grace from some of the conversations that we’ve had here and it’s not it’s not all black and white um diane and kieran i’d love to thank you for your time it’s an awesome paper that you led diane i refer lots of patience to it and the infographic is quite popular um kind of going back on to what you were saying here and around people taking this quick look at a quick glance at it and we actually ended up changing the title of it to seven surprising facts around posture instead of just seven facts around posture because i found patients would just look at it and they’d go oh yeah i’ve known all that posture stuff i’m already know about sitting up straight and it’s like no no have another look at it because actually that’s not well supported by the research and that’s not what this infographic is saying so um yeah thank you again for your time do you guys have any closing remarks so just to uh thank you kevin for the for arranging this but also for all your help with the infographics if it was left to me there would be no infographics so thank you very much my pleasure thanks guys there you have it the end of another episode thanks again for tuning in let us know what you thought of the conversation by getting in contact via ebp podcast on social media did you agree disagree were there any other points that you thought we missed or want discussed resources the vodcast script infographic and references can be found at the show notes page at forward slash podcast but until next time remember to ask is there more to pain than damage please note what you heard on this episode of empowered beyond pain is strictly for information purposes only and does not substitute personalized high-value care from a licensed and trusted healthcare practitioner we are all individuals and need to be assessed and managed as such theme music generously provided by ferven and cash

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