Episode 16b: Posture and Pain: Low back pain fact 6 with patient voice Joe, and Nic Saraceni


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 (http://dx.doi.org/10.1136/bjsports-2019-101611). 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 and Kevin Wernli welcome back patient voice Joe from episode 14 and researcher/physiotherapist Nic Saraceni. Together, they discuss low back pain fact number 6: Posture does not cause back pain. From sitting posture to lifting posture, sleeping posture and everything in between – it’s all discussed in this episode.

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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
low back pain infographic


The posture and pain infographic discussed in the podcast:
Posture infographic

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:

Nic Saraceni’s Review:

Nic SaraceniPeter KentLeo NgAmity CampbellLeon Straker, and Peter O’Sullivan

Journal of Orthopaedic & Sports Physical Therapy 2020 50:3121-130

Lifting position low back pain


Nolan D, O’Sullivan K, Newton C, Singh G, Smith BE. Are there differences in lifting technique between those with and without low back pain? A systematic review. Scand J Pain. 2020 Apr 28;20(2):215-227. doi: 10.1515/sjpain-2019-0089. PMID: 31730537.

Heneweer, H., Staes, F., Aufdemkampe, G., van Rijn, M., & Vanhees, L. (2011). Physical activity and low back pain: a systematic review of recent literature. Eur Spine J, 20(6), 826-845. doi:10.1007/s00586-010-1680-7

Coenen, P., Kingma, I., Boot, C., Twisk, J., Bongers, P., & Dieën, J. (2013). Cumulative Low Back Load at Work as a Risk Factor of Low Back Pain: A Prospective Cohort Study. J Occup Rehabil, 23(1), 11-18. doi:10.1007/s10926-012-9375-z

Coenen, P., Kingma, I., Boot, C. R., Bongers, P. M., & van Dieen, J. H. (2014). Cumulative mechanical low-back load at work is a determinant of low-back pain. Occupational & Environmental Medicine, 71(5), 332-337. https://dx.doi.org/10.1136/oemed-2013-101862

Martimo, K. P., Verbeek, J., Karppinen, J., Furlan, A. D., Takala, E. P., Kuijer, P. P., . . . Viikari-Juntura, E. (2008). Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. BMJ, 336(7641), 429-431. doi:10.1136/bmj.39463.418380.BE

Verbeek, J., Martimo, K. P., Karppinen, J., Kuijer, P. P., Takala, E. P., & Viikari-Juntura, E. (2012). Manual material handling advice and assistive devices for preventing and treating back pain in workers: a Cochrane Systematic Review. Occup Environ Med, 69(1), 79-80. doi:10.1136/oemed-2011-100214

Verbeek, J. H., Martimo, K. P., Kuijer, P. P., Karppinen, J., Viikari-Juntura, E., & Takala, E. P. (2012). Proper manual handling techniques to prevent low back pain, a Cochrane systematic review. Work, 41 Suppl 1, 2299-2301. doi:10.3233/wor-2012-0455-2299

Kuijer, P. P., Verbeek, J. H., Visser, B., Elders, L. A., Van Roden, N., Van den Wittenboer, M. E., . . . Hulshof, C. T. (2014). An Evidence-Based Multidisciplinary Practice Guideline to Reduce the Workload due to Lifting for Preventing Work-Related Low Back Pain. Ann Occup Environ Med, 26, 16. doi:10.1186/2052-4374-26-16

Hogan, D. A., Greiner, B. A., & O’Sullivan, L. (2014). The effect of manual handling training on achieving training transfer, employee’s behaviour change and subsequent reduction of work-related musculoskeletal disorders: a systematic review. Ergonomics, 57(1), 93-107. doi:10.1080/00140139.2013.862307

Schaafsma, F. G., et al. (2015). “Back pain: Prevention and management in the workplace.” Best Pract Res Clin Rheumatol 29(3): 483-494.

Mitchell, T., O’Sullivan, P. B., Burnett, A., Straker, L., Smith, A., Thornton, J., & Rudd, C. J. (2010). Identification of modifiable personal factors that predict new-onset low back pain: a prospective study of female nursing students. Clin J Pain, 26(4), 275-283. doi:10.1097/AJP.0b013e3181cd16e1

Machado, G. C., et al. (2016). “Transient physical and psychosocial activities increase the risk of nonpersistent and persistent low back pain: a case-crossover study with 12 months follow-up.” Spine Journal 16(12): 1445-1452.

Inability to perform because of pain/injury in elite adult Irish dance: A prospective investigation of contributing factors.

Cahalan R, O’Sullivan P, Purtill H, Bargary N, Ni Bhriain O, O’Sullivan K.Scand J Med Sci Sports. 2016 Jun;26(6):694-702. doi: 10.1111/sms.12492. Epub 2015 Jun 3.PMID: 26040202
Coenen, P., et al. (2017). “Abdominal bracing during lifting alters trunk muscle activity and body kinematics.” Appl Ergon 63: 91-98.
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– 1849https://doi.org/10.1002/ejp.1631



In hindsight yeah well i think that to to be honest i think that having that stereotypical good posture and keeping that upright spine all the time i think just stiffened everything up i think do you see those those prevalent releases unhealthy oh yeah absolutely abs absolutely it’s um massively unhelpful i mean we’re we’re conditioned from such a young age to to think that our backs are fragile and that we’ve we’ve got to protect them by keeping them straight especially when when lifting or loading and i mean it’s unfortunately that that’s i mean it’s just weird i sort of almost i still i still look at that box and go down to and i’m like what the hell am i doing it’s like that it’s absolutely unhelpful welcome to part b of our two-part special on posture and back pain in this episode of the empowered beyond pain podcast brought to you by body logic physiotherapy pete and i chat to patient voice joe again from episode 14 as well as to researcher and physiotherapist nick saraceni posture is clearly a topical topic and we’ve received lots of great feedback since posting the last episode mandy who’s been experiencing back pain for more than 20 years following a fusion had her mind blown after realising she has had muscles switched on that don’t need to be and by learning to relax them her pain decreased we also heard from a fellow kiwi who had injured their back twice and was experiencing psychological worries and fear they reviewed the podcast as absolutely stunning and a must listen and pleaded with people experiencing similar emotions to listen over and over until the messages sink in we are absolutely humbled by these messages please keep them coming you have no idea how much they mean to us reach out via ebp podcast on social media or better still leave a review wherever you’re listening anyway on to today’s conversation all about posture what is good posture what is terrible posture why should we perhaps lift with a round back what should our sleeping posture be and much more one thing joe talks about was his openness to change his cognitive flexibility if you will we see this as an important attribute in helping people move forward because if you’re fighting for your limitations it’s hard to move past them so with that said whether you’re listening or watching on youtube let’s get into the conversations and we’ll start by playing fact six from the 10 facts about back pain paper which is linked in the show notes as well as all the references discussed in today’s episode at www.bodylogic.physioforwash podcast and then we’ll head straight into conversations with joe nick pete and i remember to ask is there more to pain than damage back pain is not caused backward posture how we sit stand and bend has not been shown to cause back pain 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 [Music] we’re welcoming back joe who was on episode 14. uh we the topic today is posture and posture is a really common um scapegoat almost i suppose for for for back pain um but it’s a really common belief that people think this is something i need to be mindful of and we did discuss some of these things back in episode 14 but i really want to kind of hone in on this whole postural story for you so can you tell me about that uh so oh yeah i guess um where do i begin okay so uh naturally i’ve got really terrible posture i mean i i sort of slouch i’m always sitting back in my chair and uh you know i’ve got what a lot of people say is is terrible posture i sort of stupid and but but i guess uh one of the when i had my experience with my pain i sort of changed all that uh it was it was weird uh so as soon as i sort of thought well maybe maybe posture is part of the reason why my pain is so bad so you know almost overnight i i i started sitting upright sitting upright i never never sort of relaxed i was always you know trying to do these things and i tell you what it didn’t make anything better really so i mean i guess i changed i changed the way i stood the way i sat the way i’ve slept the you know everything changed when i sort of had back pain and and i thought that it would make things better by keeping everything upright and straight and give everything a chance to heal but but really i think it just made things a bit worse so it’s interesting that you kind of had these rules around posture joe and and they pervaded a number of things you said sitting standing bending lifting sleeping even oh yeah where did you get them from oh goodness probably tv newspaper media articles right the internet got googling back pain you know you know how can i treat my back pain it’s like oh you know five different postural techniques blah uh look i mean i guess you know i’ve as i said i used to have what what a lot of people would call terrible posture i think i sort of slouch and stoop over a bit so i mean i’ve been getting told my whole life that i’ve got bad posture and so i was like oh well so you were pre you were primed yeah that’s right i think that your posture was a cause yeah absolutely well i thought well what can what can it hurt to try and have a a better posture so yeah absolutely and then i sort of that sort of fed into i wanted to also get my core nice and strong and so everything was sort of upright but but yeah it was it was weird i was i was always sort of feel like to be you know obviously before you had back pain yeah you were relaxed and slouchy and yeah you didn’t have back pain loose yep yeah and you didn’t have back pain it wasn’t a problem once you’ve got back pain you changed all of that what was it like to have to think about holding your posture straight all the time exhausting it was it was sort of like a workout i mean if this this situation this straight back stuff is is not how i want to be sitting so i guess i was working so hard all the time to sort of have that posture i was exhausted was it mentally and because obviously having to think about it all the time as well yeah well i mean on top of that because because it sort of fed back and my back was really sore and niggly it was sort of like every single time i sort of went like that or like this or you know something would twinge or hurt or it was it was sort of weird it was it was exhausting to just sit up all the time i mean and what about movement so because you were trying to hold those postures when you moved oh you said absolutely i i mean you always get told lift with a straight back you know don’t don’t bend too much don’t bend when you lift try not to twist don’t load and twist like you sort of get these these work that you got told that at all i think it’s in all the workplaces i’ve ever worked i mean you just you always see signs you know and even on a box you get a package that’s you know 20 kilos there’s a sign of two people lifting a 13 kilo box with bolt upright postures and bent knees and you know making sure they’re not bending at all yeah it’s like i mean you know 6.5 kilos each and yeah just bend over and pick it up but it is yeah but you sort of get conditioned to think that that straight must be good for your back yeah um and you just completely neglect the whole range of motion that your back is okay and did that make sense to you at the time um i guess as i’ve said you know you can you see it on the walls on boxes on packages at work uh on the internet you just get conditioned i guess well i certainly got conditioned to think that you know having a straight back was good for your back and and so yeah uh yeah it it it it did make sense even though as a ex-sport scientist you sort of think well hold on you’re always telling people you know when you’re exercising go through the full range of motion if you if you’re doing a bicep curl i mean it’s pretty simple exercise but you know go from straight to all the way up you don’t you don’t just work that sort of range of motion you you go through the full range of motion so it’s sort of weird it’s sort of like you you get conditioned to think no straight back but then that sort of so off with the way you think about every other bit of your body which is go go through the range move but um yeah it’s so yes it made sense but it also doesn’t make sense so it’s in hindsight especially in hindsight it doesn’t make sense all right so do you how do you see it obviously you know you’re one person and a lot of people who have back pain yeah and so we can’t generalize you to others but um like what what is your understanding what was the relationship between posture and your back pain do you think in in hindsight yeah well i think that to to be honest i think that having that stereotypical good posture and keeping that upright spine all the time i think just stiffened everything up i think that when you when when i for me uh only when i was only working one range of motion in my back which was bolt upright i think of course if you if you hold any joint in your body still or put your arm in a cast or put your leg in a cast that when you first start moving that’s going to hurt you know it’s going to be stiff it’s going to be sore and the problem was is that i was sort of making my own cast for my back and then when i felt that pain i thought oh well that’s because that movement’s bad for me so i better go back to being bulked up right because that was the only range of motion i was in that was the only range that was pain-free yeah so it was um it was it’s just bizarre really i mean yeah so when you started to change because clearly you’re not sitting up right now what was that like to think that actually how was it to think that that might not be the case oh look it was it was actually liberating because i mean i think i had such a long history of what i was doing not working right that um i was pretty i was fortunate that i was pretty open to change when i when i had the inter you know when i got the right help so i mean i was happy to really just just pump all that old information and just try something new because i thought well what have i got to lose if i if this doesn’t work what am i losing you know i’ll just end up going down the surgery route anyway so it’s like well why don’t i give something new a shot and then obviously once i got to be able to do everything that i wanted to do anyway i was like well this is better my pain’s decreased why don’t i just do what’s natural so did it seem strange to be given completely opposite information oh then what absolutely the common belief is absolutely but i was such a willing victim um but yeah it it did it what i guess the thing that crossed my mind was it was about three or four months on when when i’d changed everything i was doing everything completely different i was lifting with a with a rounded spine just because i was thinking well i mean it makes so much sense i mean if you’re always lifting with a straight back and then you go to lifting with a curved spine yeah you you might hurt yourself because you’re not conditioned to lift in that right in that way yeah but if you start light and condition you i mean you can lift with your condition to lift the way your condition got lifted so your exercise fizz training tells you that and yeah absolutely and so i just thought well about three months in i was wondering why i got the other advice in the first place i i just thought well this is so obviously the right way to go i mean it just like so you’re telling me i should move naturally and then my pain also almost we went from a 7 8 9 10 sort of range because back pain is horrible everyone out there who suffers from serious back pain knows how debilitating it can be so when my pain was going from these high levels to low levels doing what i wanted to do anyway i was thinking well why the hell was i ever given the advice to move so unnaturally it just didn’t make sense to me so yeah yeah i and what about those around you because as you say it’s very common and your workplace as well yeah absolutely you know those messages are common so how how was it for you to kind of break those posture rules in your social environment your work environment at the gym exactly et cetera as well look i mean it was very easy for me to break those rules because i mean i was just felt so good felt so good i was going out of sight i felt i was moving again i was i was you know doing things i hadn’t done for years and i was i was stoked so i mean it was very easy for me but i i mean i remember i was i was lifting in the gym one day doing a really nice spent back deadlift and just you know everything was nice and curvy and it was feeling great and uh and a boss of mine went past and he said geez you’re going to do your back lifting like that and i thought well i actually said to him i said it’s actually funny you say that because this is the very sort of behavior that’s helped me uh get over my back pain and and you know and he just well god and you just but it’s amazing how prevalent that information out there is that you’ve got to lift with that really neutral neutral spine yeah but um and it’s big in gems it’s big in gyms it’s big in workplaces i mean it’s it’s amazing as as i said it’s on every single delivery you get that’s over about 10 kilos if someone is a picture of someone picking it up using only their knees lift with your knees not with your backs you know lift lift with your condition to lift and make sure you go through your range of motion yes is the advice that i would have given myself back then yeah but um yeah it’s it was easy for me to break the rules but i started getting more and more because i mean i at this stage i i had a history of back pain and i was going to work still so i mean everyone knew that you know i had a bad back now everyone knew that i had a bad back it was it was just uh you know from from you know three years earlier that i sort of heard it and i never came good so everyone sort of knew and so when they saw me in the gym doing all these these things i got a lot of questions and and it’s amazing how quickly i sort of found out that it wasn’t just me who had a history or an issue with with back pain there was so many people and and family members friends friends of friends there’s so many people dealing with this is a huge problem and and all of them have the same beliefs around if i if i lift with a neutral spine i’m less likely to damage my back yeah right um and and then slowly the questions became more oh wow you’re you know you’re getting really fit you’re getting really healthy how’s your i mean god i was getting asked for about the next six months so how’s your back doing all that it’s like well my back’s really good my back’s about to be pretty normal yeah and then slowly other people who you know i knew had issues as well started asking me for my exercises to which i sort of said look my advice would be to go and see my problem isn’t your problem yeah so i would do this in in consult with yeah health professional with with professionals because i mean i can’t say that you’ve got the same thing that i have but i mean i definitely pointed them in the direction of where i sought help and where i thought that they should be looking and um a lot of them have since had really effective treatment and back to being normal i mean i’ve i’ve got friends of mine one of them in particular i know he’s he’s had an issue with back pain since he was about 20 and he’s he’s in his he’s almost 60 now and i mean and he’s now absolutely living living the dream he’s killing it he doesn’t he just he doesn’t have a problem anymore and this is just you know all because he just sought the the right help and and i guess was willing to to ditch his previously held beliefs around so do you see those those prevalent beliefs unhelpful oh now if you look oh yeah absolutely uh abs absolutely it’s um massively unhelpful i i mean we are conditioned from such a young age to to think that our backs are fragile and that we’ve we’ve got to protect them by keeping them straight especially when when lifting or loading and i mean it’s unfortunately that that’s i mean it’s just weird i sort of almost i still i still look at that box and go down to and i’m like what the hell am i doing so it’s absolutely unhelpful how hard do you think it will be to change that well it’s a question i ask myself every day by career unfortunately i reckon there would not be a person i would see one comes through my door okay well that’s not entirely true it’d be the absolute majority of the people i would see who i would who would seek here who would hold those views not everybody but almost everybody unfortunately uh i mean i think on an individual level it’s very easy to reach and an individual yeah if you maybe not easy is not the right word but it’s possible it’s it’s doable to reach an individual and and in a one-on-one you know session you know appointment an hour long to get them to think about these things and and to change but but to change it on i mean i i don’t know the numbers but they’re millions and millions and millions of people worldwide suffering from back pain so to change the the message as a whole i i want an impossible task i mean and i i i do know that there is a fair bit of resistance out there to change have you seen that yourself oh to a degree but i mean a lot of the time when i’m talking to people it’s it’s on a one-on-one and they sort of go well and these are people that know me and trust me and they’re friends of mine and so and they know where i was and where i am and so it’s it’s quite easy for me to to talk to so i don’t see the the i guess i don’t see the issue with everyone i just i speak to individuals and i think it’s possible to reach individuals but how do you reach 50 million people one at a time it’s impossible and unfortunately it’s such a large-scale problem that to help people one at a time when it’s one of the problems we have is that um it’s legislated that you have to educate people who are in manual jobs around and if we touch on a bit of the research we know that there’s not a single study that shows that teaching people how to live better so called better oh god reduces back pain i i rarely still but we still let’s let’s just like i read some nonsense study about because i i sort of after i changed my my ways i sort of thought well where does this message come from and correct me if i’m wrong but it came with cadaver spines and loading them and bending them and and then the tissue would break down they went oh well the tissue there broke because we moved it yeah in this dead spine and and so that must be bad for you yeah but i mean if you did the same thing with any joint and a dead dead joint it would wear out if you used it but yeah that then doesn’t take into account the fact that we lay down new tissue yeah we’re we’re living yeah exactly so oh god i i mean if it’s a nice jump if that’s if that’s where it all came oh and and what’s the other one they put a pressure meter into a disc and then they bent the spine and the pressure went up so they went oh well that must be that must be bad yeah loving makes you stronger yeah yeah that’s right oh god anyway yeah i’ll discuss that in episode four quite quite indeed actually i kind of want to round it up with a couple of kind of key take-homes for people at home in terms of with posture this whole idea you know there’s a the ergonomic industry when you go to any big office or workplace there will be signs saying uh you know this is how you want you to sit keep your screen at negative 10 degrees uh knees and hips at 90 degrees keep your feet straight um what are your thoughts about that oh look i mean it’s all it’s all quite funny isn’t it like yeah whatever you do you whatever you do you must not sit comfortably um you you must be put in a in a position of maximum discomfort no uh i don’t know it just it it it doesn’t make any sense i mean we’re all so different we’re different shapes we’re different postures we’re different we’re different in so many ways and so to to the idea that there is an ideal sitting position for everyone is it just doesn’t make any sense so i i would argue against it if if that got brought up then someone said to me oh look this is the way that you must sit and and that’s the best sitting position i would i would argue uh for the negative on that one that’s interesting i’d love to just pick on one little thing that just triggered that and that’s sleeping because we often don’t talk about sleeping as a posture but we know that sleep is an incredibly important thing for people we know that back pain can really really impact on someone’s sleep oh and a sleep deprived person’s greater predisposition for pain anxiety worry fatigue you know ill health generally it’s it’s such an important thing what what were your thoughts around posture and sleep so i i got told that sleeping on my back or my side was better than sleeping on my stomach for for my back i always found it really comfortable and i i do now again find it really comfortable sleeping on my stomach right um it’s just how i’ve always slept and that when i was going through my my issues with pain i i changed because i wanted to have a more uh back positive postural so i ended up sleeping on my side made sure my my hand was supporting my head so that was all straight with a with a pillow between my knees because i heard that that was that was a good thing to to do for your back so you can just spine i was keeping my spine exactly the same way as i kept it for the the 16 hours before that was also exhausting so um yeah no i i just even even when i was sleeping how was that to sleep like that oh well i i think that i know of people that sleep like that who that’s how they sleep and they’ve always really enjoyed it it’s fine for them for me it was terrible it wasn’t it wasn’t that relaxing and every single time i woke up like rolling or rolling towards my side i’d quickly go oh and i feel like i was flying out to go back to you know my my correct my correct sleeping position because the other thing that taps into is what we call vigilance it’s like oh yeah constantly thinking about oh absolutely i was worried that if i went into too deep asleep i might roll onto my stomach and then screw my back up right okay so that kind of constant thought on oh posture created a whole abnormal focus on your body that became really unhelpful just became a monster yeah yeah absolutely yeah so no [Music] two years ago when i was going three years ago when i was going through all this it was it was not funny at all and it’s it had it had an absolutely terrible and uh detrimental uh effect on my life my mental health my job my activities everything it was um i was in a really really horrible place i only only laugh about it now i guess because just the the ideas that i had around how i was going to help myself are sort of the exact opposite i guess of of what ended up helping me so it was um yeah it’s it’s kind of weird it’s it’s a it’s a weird comical irony that um yeah which is which is why it’s kind of funny yeah now now exactly yeah awesome i want to um summarize with the whole idea of this um this one-size-fits-all is what you sort of mentioned before i think the other way to think of that which i often use or to kind of rationalize this is trying to say that everyone needs to wear a size 7 shoe and we’ve all got different size feet some are longer some are shorter some are wider and for those people that have size 7 feet that’s going to be really good advice yeah but but for everyone else it’s kind of like you’re trying to make them fit into something that their body is not really natural or designed to do no and you might sort of mention yeah to start um that you’ve always had terrible posture i think it’s pretty safe to put that in quotation marks yeah yeah yeah um and this is normal posture sounds yeah you know i mean like look at look at us i’m kind of off camera now about you know where we we like to vary our postures we relax when we’re sitting uh we get up and up and down frequently yeah if it’s if it’s comfortable keep sitting there yeah and then if it gets uncomfortable we’ll go oh that’s a bit uncomfortable that’s comfortable that doesn’t mean that sitting up straight it’s dangerous or bad for you or anything like that either but it’s about variability if it feels good do it the best posture is your next posture yeah that’s right cool thanks joe thank you no worries thanks heaps what a great chat that was we reckon joe’s story is so relatable and unfortunately so common and he articulates his thoughts so well so we’ve heard the patient perspective intertwined with some research but now let’s hear about what the research has to say and specifically what nick saraceni has to say a researcher and physiotherapist whose whole phd topic is on lifting posture and low back pain we’re here with some researchers who are both researchers and clinicians um nick particularly uh your whole phd is on lifting related to low back pain so both as a researcher and as a clinician what would you say some of the common misconceptions are that patients have when they come and see us as clinicians um related to lifting and low back pain definitely for me without a doubt the most common misconception is that there is a optimal weight lift that you should keep your back straight and you should bend your knees um and that is the best way to lift to prevent back pain but also if you have back pain that is definitely what you should do that is a dominant misconception yeah and and what does the research tell us around what actually you know what advice would we give patients like this so what is that what’s the fact i suppose well we my part of my research is all about that exact question um where we’re trying to figure out if there is an optimal lifting posture and probably in a researchy kind of answer that there might not be um that we we don’t know if there’s an optimal lifting posture and definitely at this stage not for everyone um so the fact would be that at this stage we we need more um research in this space but often it’s it’s the opposite of what we think that when we looked at a review that we did most people actually with back pain were keeping their back straight up following following that advice and and bending their knees more and that comes across in my systematic review but also in david nolan’s so the fact is that we don’t know but it doesn’t look like that keeping your back straight and bending in it bending your knees more is a you know going to help everyone yeah sure so that’s kind of talking to that i suppose that ergonomic advice in terms of we often hear that people should be um keeping their back straight and and bending with their knees and lifting with their knees do we know that lifting occupations are related to back pain like if we have manual laborers and manual workers is there an association there with those occupations and and having back pain so there is there is so if you’re in a manual job um what the evidence would say is that if you lift a lot lift often more than 25 times per per day and also if you lift heavy quite often um that you’re at greater risk your risk goes up as the heaviness goes up and the regularity of lifting goes up um but we we’re not we’re not sure why so there is elevated risk slightly um but if it’s to do with posture or not we don’t know it could be a bunch of other things such as you know how much load is going into your back how used to that load you are what your capacity is like what your fitness is like how you perceive that load does it feel heavy for you or does it feel light all these things seem to maybe matter um maybe more or um as more than posture or at least you know they’re they’re we don’t really know but they might be just as important as posture but yeah um you are at slightly greater risk yeah sure and and is there kind of um we know that there’s lots of ergonomic interventions you know there’s programs out there that are teaching people how to lift and um you know how to position their spines correctly what’s the evidence for those are they effective at reducing back pain in a short word uh probably not yeah short answer probably not um probably not no is there any evidence for it nick had a systematic reviews of ergonomic interventions to reduce the risk of back pain in summary no yeah nothing that we know of that it’s probably not helpful so it isn’t helpful based on these two systematic reviews that showed that either people aren’t following the advice so they don’t follow it um to keep back straight and bend your knees and that kind of ergonomic advice um or uh it’s just not a useful advice so yeah so if you think of that about that though nick it would seem from your review and nolan’s review that they are following the advice yeah true so it sounds like option one probably isn’t the case because this idea of well if they weren’t following the bias and they just like bending over and lifting the way they normally would then maybe that’s why they’re not sore but in actual fact so dave nolan’s review um showed that they were lifting with straight up straighter backs and more bent knees so it looked like they were following the advice and the people with back pain lifted more like that than those without back pain who had tended to be more of a stoop lift than a straight back squat lift that’s right so it would suggest that actually people with back pain revert back to the advice they’ve been given at least that’s right yeah once they get back pain people are tending to follow that advice yeah we don’t know what happens before they get back pain whether they’re lifting in a different way there’s only one study that looked at that tim mitchell study and it showed that there was no differences but once they get pain they people seem to revert to this advice where they keep their back straight and bend their knees um and obviously they’ve got pain doing that so it’s like you’re saying pete’s probably not that useful so one of the things i suppose i’d ask is a devil’s advocate on this because there are some really strong beliefs around back pain and lifting what were the limitations of the studies you reviewed so how much were they left how much did they lift how heavy were they did they lift a loss was it repeated lifting because you’ve said that your risk factors are heavy lifting and repeated lifting what are those studies actually done so they looked at um up to 12 kilos some of them were really light like a pen um but others were with weight of up to 12 kilos in a box so that was the and that sort of encapsulates you know your regular occupational lifting i suppose but nothing heavy um so that was one limitation it’s light lifting um and there’s a a bunch of other limitations like you know how many they lift usually there’s only three lifts that they captured right um so there’s some weaknesses like you’re saying to that really capturing the risk in a sense if you talk about heavy lifting repeater lifting 25 lifts minimum in a day yeah is where the risk is they’re not that that research would suggest that there’s a bit of a jury out at the moment definitely yeah around this the jury’s definitely out for sure but if it was pointing to a direction if the jury could point it would be saying that people with back pain are tending to actually keep their back straighter not actually around their back more there’s nothing that points in that direction yeah we just don’t have the evidence at this stage and a part of your phd is trying to help answer that obviously yeah we’re pretty keen to get you back to talk about your phd next year when you’ll have a lot more answers for us yeah yeah around and maybe you can give us a bit of a um a taster about not of what you’ve found yeah because it’s not published yet sure but what you what your studies done to kind of bridge some of the gaps in the the existing literature yeah so we some of the gaps um are that we recruited people who are in lifting jobs that either they’ve had a long history and career in a lifting job and they’ve had no problems with pain and or the other group that we recruited are still in lifting jobs but have difficulties with with pain related to lifting so we’ve captured groups like no other study has previously relevant um cohorts that and then tested them how they lifted so we got them to lift um up to 10 of their body weight a hundred times and we’re going to lift and twist in a task that replicated work tasks and we measured lots of things knee bend trunk speed back position all the things that people think forces might be relevant and we we captured that to try to address some of these limitations and you used really accurate measurement tools where i think some of the previous studies had had not all of them but a number of them have pretty limited measurement tools yeah look at accuracy what was happening in the lower back exactly yeah we we tried to capture curvature in a way where a lot of studies just looked at you know the the whole trunk almost so people think that curving the back’s important previous studies didn’t look at that we actually looked at you know what’s happening in the curvature component of it so i’m interested nick given you know this is an area that you’re obviously interested in and you’re researching in and you’re also a clinician so if a patient comes to you and they’ve got back pain and they’ve heard it lifting um how do you kind of um and they say to you look i i don’t i don’t want that again it was a horrible event how do i prevent it where does it where does evidence sit now at the moment for what we can say sure it’s good it’s a great question and probably probably how i would go about it in a cl if i put my clinical hat on um would be that i would ask that person questions around a whole a number of factors um not just about how they lifted it but to do with you know how often they’re lifting it what’s what’s been happening around the time of the onset of pain because what we know is that um yeah posture might be one part but we there could be a whole bunch of things around you and not sleeping more fatigued changed part of the activity levels so i’d be wanting to know what what’s surrounding the context around when they got that pain um and then i’d dem i’d get them to demonstrate how they’re lifting if lifting’s still giving them trouble i would look at how they’re lifting and then seeing if if we could alter anything change anything and try to you know reduce it going forward so that they would get back to work and get back to lifting how they previously were okay so there are a number of things that kind of emerge in that as i hear it and that is around risk factors so we know from the research that um lifting per se can be a trigger so awkward sudden lifts repeated lifts are a trigger of back pain but that risk massively increases if you’re fatigued or tired at the time so that tips into some of these other things around potentially stress related factors sleep general activity levels of conditioning etc so it looks like there’s other risks involved the other part that i think um it’s important that you highlight is that um someone’s risk of pain is multifactorial and so just focusing on one aspect of like how you left maybe missing a bigger story yeah and so that exploration around that but the at the moment we don’t have a lot of research evidence to say you know this is the way um we do have some evidence to suggest that there are more efficient ways to lift and that contradicts a lot of common belief that actually you know around back lift looks like it’s more efficient in terms of the the amount of load that you can generate force you can generate in the body but that again that has to be explored um further i think um what one of the things that we look at when we we kind of look at people’s risk is the critical aspect of history taking but also no different to spraying an ankle you would never tell someone a sprained ankle never to invert their ankle again you would say look for a period of time just we back you off we’ll get you mobile we’ll get you strong we’ll get you fit we need your ankle to be able to move in all directions so it’s competent to load in a variety of ways and backs should be able to do that as well and i think that’s the story that often gets missed around backs is that bac’s health is related to ranges of movement you want strength in a variety of ways you want to teach your workforce to better adapt to load and in a whole variety of ways because you know each one of us would come across manual workers who will say i can’t do optimal lifting in my job it’s not possible so if we’re not equipped to do it then we may be vulnerable when we go to do it do you think that’s a reasonable way of looking at it i’d say so it sounds like it’s pretty evidence packed and uh i know we’ve had a discussion about the the issues around you know foot strike for running yeah around back posture and foot posture yeah you know we there are a lot there was a whole rage around mid-foot running or rear foot running and shoes but really the evidence isn’t so flash on that and maybe the same thing fits with the back it’s like fitness for lifting so there might be some efficiencies around certain patterns of running like high cadence but it looks like the exact foot posture is not so critical maybe that’s more what we should be thinking about around backs yep and i think that it’s practical you know like saying to someone like you’re saying keeping your back straight for every single lift doesn’t seem that that doable especially from the data we captured but in real life i mean it’s just definitely not practical all of the time so making people strong and resilient to certain positions and movements that they’re having to be exposed to at work when they’re lifting and being capable in a range of postures like you’re saying probably it might be better than saying do it exactly like this every time but we have to test it i suppose yeah i think the other thing it kind of springs to mind as a clinician is that there’s so much fear and we know that lifting is one of probably one of the most feared activities or bending and lifting for people with back pain is and it’s often linked to an experience where they’ve actually hurt their back when they do bend or lift and so it becomes a memory that they guard against and we know that when you’re frightened you tend to over protect that area and over protecting can over create more load on the area and so that potentially can set someone onto a cycle where they over protect an area they overload it they don’t move it as much it compromises the health of those structures that leaves them more vulnerable to the event again so there’s that whole other space around buildings people people’s confidence in their back to go back to lifting normally yeah and the question then is what does normal look like and that’s something i think your research will give us a better insight into is you’ve looked at survivors people who’ve lifted an industry for what more than five years five years repetitively and haven’t hurt back pain so they will give us a bit of an insight into what is a person who survives a manual work look like in terms of the way they go about doing that how would that be interesting that’ll be interesting it will be answers shortly some common sense answers from from us from you both which is great i want to sort of finish with um what about people that don’t have back pain so we’ve got advice for people with back pain what about you know the general population that hasn’t got a problem with their back what advice should we be giving them when they’re lifting things do you want to go first nick yeah i think we’ve touched on a number of these things that pete and i have touched on today around you know looking after your whole health for example you know keeping yourself fit and strong and active they apply to obviously people without back pain too and building capacity for the job that you have so if you’re a heavy um landscaper you need to be strong and fit and healthy and capable to do that job so that that seems like a a job you’re ready to do you’re prepared for it um all that advice is for people with um without back pain as well and probably i’ll say if you’re lifting in a way that doesn’t cause you trouble i wouldn’t change that whether that’s curve back or straight back or bent knees if it doesn’t give you any trouble i’d see no need to change it that would be probably how i would address it yeah yeah i kind of look at the issue around lifting is someone who says i want to run so we often hear people who’ve got a sedentary job when they get out on the you know on the weekend and just go nuts in the garden and they’re not conditioned for it and they hurt their back and like yeah what have i done it’s like oh i can’t lift now i go well if you were someone who was sedentary all day and then you went and run 12 k’s in the city to surf and you said my knees and ankles and so we’ll go figure like you know you’re not conditioned to run 12 k’s yeah you are not conditioned to do 500 repetitive bends and heavy loaded because your body hasn’t been conditioned to do it and i think this idea that some things are good or bad for the body is something really unhelpful um we know the body is an amazing adapt amazingly adaptable system and that we are good at doing things as long as we grid into it gradually so this idea of things being good or bad i think it’s really unhelpful this idea of being fit for task and i think you’ve touched on that um of like getting people you know lifting is a wonderful way of keeping your back strong you know we before we had gyms we had gardens um you know then we gave our gardens away and we got gems so it’s like you know it’s like that’s what we’re designed for and you look at countries around the world you know lifting and vending is part of our world yeah um it’s something we should be encouraging people to have confidence in i think it’s something that it should be safe for people and the idea around that is going you know what are the most efficient ways for you to do that and so keeping strong keeping fit keeping engaged variability and movement looks like it might be something also that could be important for the health of any system theater joint or you know the spine um and caring for your whole health that’d be the key things that we would look for yeah but in saying that you know we are human beings we get pain um i get back pain very frequently but it the key thing is what you do about it and i think we always have these messages if you hurt your back you got to rest and protect it we know that’s not helpful you know if if you’ve you know got some serious pathology sure you might have to lay off but for the majority of back pain if you’re engaged with activity you may get soreness it may be a reason to just grade down but not to arrest it and avoid it i think that’s the other big message i’ve put out there for people who might be listening to this is that you know back pain can be scary but it’s very really dangerous um in terms of you know doing some serious damage to you to your health as long as you’re sensible and put sensible parameters around it and grade into it and make sure that your body’s fit and condition for the task maybe a last message of hope i mean i’ve seen so many people that you know have lifting pain they come in with horrendous lifting pain and they keeping their back straight or you know tensing up a lot and really worried about lifting and so many of them are able to get back to the work that they want to get back to by maybe slightly changing the posture or changing the way they move a little bit uh or just exposing them back to things that they couldn’t do so gradually like pete was saying building them back up to the things that they and it’s it’s happens all the time clinically um so you know if you if you’re out there and you haven’t lifted and you’re avoiding lifting then maybe that’s the one thing that you want to try and get back to and interestingly you save that neck because from a clinical point of view if lifting is something that you avoid that that would be the first thing that we’ll look to get you back to so because we know that avoidance will make you more vulnerable to the thing that you’re avoiding um we’re engaging with it as long as it’s done in a graded and sensible and a safe way is the way to get back to it yeah i think it’s terribly important message as well yeah absolutely often people sort of think oh if lifting’s the thing that caused me the pain then i’ve got to stop and avoid doing that because that’s bad but actually progressively doing more of that what you’re saying is that will make them better and and more protective and less likely to have pain yeah and the pain related to lifting may just be a sign that you need to get more sleep that you need to care for your health the better you need to might need to lose a bit of weight that you might need to engage in more regular physical activity and fitness and care for other aspects of your health and i think there are things that we tend not to see people think about and it’s only when they reflect around what was going on at that point in time yeah they can see sense in that yeah just doesn’t seem to be purely about posture the only other thing i know i you know i probably need to add into this the other very common belief that i’m sure you guys see and i would almost invariably see this is this idea that you should engage your core when you lift and um that’s probably the other most common thing i would say we did a research um study a couple years ago so emily campbell and um a couple of other researchers were involved where we got people to just lift 15 kilograms off the ground and we looked at their abdominal muscle activation standing before they lifted as you know lifting the weight and putting it down we found the abdominal wall muscle internal blades so the you know core muscle group that people were taught to engage were no more activated in lifting than they were just arrested standing so basically the muscles don’t naturally engage when you lift now what patients are told is that you know when you’re left you’ve got to brace your core as you go to do it to stabilize your back and i think the common misconception there i kind of described that as a bit like you know if you think of what these muscles are designed for they pull you to the floor so they work against your back muscles so they put double work on your body in fact you can do a simple test yourself by doing repeated lifting with your core brace versus your belly relaxed and see what it feels like it’s much harder work when you engage your core so in actual fact we’re teaching people to pre-load their backs and pre-stiffen their backs before they do a task which is if they do that repetitively they’re going to fatigue way quicker so there is not good evidence actually to suggest that if you don’t do it normally why would you teach it and be how i would look at it and often we have to train people out of bracing their call when they left i actually find that it takes a lot of pressure off their back because they’re just not loaded they’re not double loading not just carrying the weight of their body and an external load but they’re actually generating an internal load by co-activating their core muscle so that’s probably the other thing that comes as a surprise to people when we look at retraining them to get back to manu work is that it’s actually not smart to consciously engage and that idea of um you know having to pre-pre-contract a muscle before you do something it’s not anything we do with any other motor task you know we don’t do it we kick a ball or play a musical instrument or you know like do any other motor activity but somehow we’ve done that for the back where we’ve created this belief that this back is so damn vulnerable you’ve got to pre-tense things before you do it which actually loads the body more it fatigues you more it puts you on alert more probably decreases your confidence to doing stuff and it certainly doesn’t improve your performance yeah exactly and dave nolan showed in his paper that actually people were in pain were tensing their like people exactly they’ve done was more they were stiffer and more co-contracted exactly in their abdominals yeah then more than the people without pain yeah and the other way that i like to explain with patients is like we’ve got lots of cranes here at curtin at the moment there’s lots of buildings going on cranes have the cable at the back so when they lift something up they put tension on the cable at the back to lift that thing up bracing your core tensing your abdominal muscles is like also putting a cable at the front correct to pull it down while you’re lifting it up it’s like extra tensing your bicep and your tricep at the same time it just doesn’t really it’s not conducive of efficient movement so the cable at the back looks like your back muscles your butt muscles and your hamstring muscles that’s where your cable sit in fact your hamstrings probably a critical cable at the back end if you’re thinking of a crane yeah um the other muscle group you want to get working i would say you’re doing lots of bending and lifting exactly absolutely awesome thanks gents really appreciate your input thanks kid so there you have it 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