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:
From this paper:
Other Supporting references:
Nic Saraceni’s Review:
Journal of Orthopaedic & Sports Physical Therapy 2020 50:3, 121-130
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.
Joe: In hindsight, I think that to be honest, having that stereotypical good posture and keeping that upright spine all the time, I think, I just stiffened everything up.
Male host: Do you see those prevalent releases as unhealthy?
Joe: Oh yeah, absolutely. Absolutely. It’s massively unhelpful. I mean, we’re conditioned from such a young age to think that our backs are fragile and that we’ve got to protect them by keeping them straight.
Especially when lifting or loading, and I mean it’s, unfortunately, I mean it’s just weird. I sort of almost, I still look at that box and go down too. And I’m like, what the hell am I doing? It’s like that. It’s absolutely unhelpful.
Male host: 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 the 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.
We’ll start by playing Fact 6 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.physio/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?
Michelle: Back pain is not caused by backward posture.
Male Host: 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.
Male Host: We’re welcoming back Joe who was on Episode 14. The topic today is posture, and posture is a really common scapegoat almost I suppose for back pain. 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?
Joe: So, oh yeah, I guess. Where do I begin? Okay, so naturally I’ve got really terrible posture. I mean, I sort of slouch. I’m always sitting back in my chair and, you know, I’ve got what a lot of people say is terrible posture.
I sort of, stupid, but I guess when I had my experience with my pain I sort of changed all that. It was weird. So as soon as I thought, well maybe posture is part of the reason why my pain is so bad, almost overnight I started sitting upright. Sitting upright, I 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 guess I changed the way I stood. The way I sat. The way I slept. You know, everything changed when I had back pain. And, I thought that it would make things better by keeping everything upright and straight and give everything a chance to heal. But really, I think it just made things a bit worse.
Male Host: So it’s interesting that you had these rules around posture Joe. And they pervaded a number of things you said – sitting, standing, bending, lifting, sleeping even. Where did you get them from?
Joe: Oh goodness. Probably TV, newspaper, media articles, the internet, I got Googling back pain, you know? How can I treat my back pain? It’s like, oh you know, five different postural techniques blah blah.
Male Host: And from healthcare practitioners?
Look, as I’ve said, I used to have what a lot of people would call terrible posture. I think I sort of slouch and stoop over a bit. I’ve been getting told my whole life that I’ve got bad posture. So I was like “oh well”
Male Host: So you were pre, you were primed?
Joe: Yeah that’s right.
Male Host: To think that your posture was a cause?
Joe: Yeah absolutely. Well, I thought, what can it hurt to try and have 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 it was weird.
Male Host: So what did that feel like? Obviously, before you had back pain you were relaxed and slouchy and you didn’t have back pain. 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?
Joe: Exhausting. It was sort of like a workout. I mean, if this situation, this straight back stuff is not how I want to be sitting. So I guess I was working so hard all the time to have that posture. I was exhausted.
Male Host: Was it mentally? Because obviously having to think about it all the time as well?
Joe: Yeah well, on top of that because it fed back, my back was really sore and niggly it was sort of like every single time. I went like that or like this or you know something would twinge or hurt. Or it was sort of weird, it was exhausting to just sit up all the time.
Male Host: And what about movement? Because you were trying to hold those postures when you moved?
Joe: Absolutely. I mean you always get told to lift with a straight back, you know? Don’t bend too much, don’t bend when you lift. Try not to twist, don’t load and twist.
Male Host: Was it at work that you got told that?
Joe: I think it’s in all the workplaces I’ve ever worked. I mean 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. I mean, you know, 6.5 kilos each and yeah. Just bend over and pick it up. But you sort of get conditioned to think that that straight must be good for your back. And you just completely neglect the whole range of motion that your back is okay.
Male Host: And did that make sense to you at the time?
Joe: I guess as I’ve said, you see it on the walls, on boxes, on packages at work, on the internet. You just get conditioned I guess. Well, I certainly got conditioned to think that having a straight back was good for your back and so yeah.
It did make sense. Even though as an ex-sport scientist you’re thinking, well, hold on. You’re always telling people when you’re exercising to go through the full range of motion. If you’re doing a bicep curl, I mean it’s a pretty simple exercise, but you know, go from straight to all the way up. You don’t just work that sort of range of motion. You go through the full range of motion, so it’s sort of weird that you get conditioned to think no straight back. But then that’s so off with the way you think about every other bit of your body which is to go through the range.
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 at all, right?
Male Host: So how do you see it? Obviously, you’re one person and a lot of people have back pain. And so we can’t generalise you to others, but what is your understanding? What was the relationship between posture and your back pain do you think?
Joe: In hindsight, I think that 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 for me when I was only working one range of motion in my back, which was bolt upright, I think of course. 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 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 upright. Because that was the only range of motion I was in. That was the only range that was pain-free. So it was just bizarre, really, I mean.
Male Host: So when you started to change, because clearly, you’re not sitting upright now. What was that like? To think that might not be the case?
Joe: Oh look it was actually liberating. Because, I mean, I think I had such a long history of what I was doing not working. That I was pretty fortunate that I was pretty open to change. When I had the, you know when I got the right help. So, I mean, I was happy to really just pump all that old information and just try something new.
Because I thought, well what have I got to lose? 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, 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 has decreased, why don’t I just do what’s natural?
Male Host: So did it seem strange to be given completely opposite information to what the common belief is?
Joe: Absolutely. But, I was such a willing victim, but yeah, it did. I guess the thing that crossed my mind was it was about 3 or 4 months on when I’d changed everything. I was doing everything completely different. I was lifting 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 lifting with a curved spine you might hurt yourself.
Because you’re not conditioned to lift in that way. But if you start light and condition, I mean, you can lift with your condition.
Male Host: So your exercise fitness training tells you that?
Joe: Yeah absolutely. And so I just thought, well about 3 months in, I was wondering why I got the other advice in the first place. I just thought, well, this is so obviously the right way to go. I mean, so you’re telling me I should move naturally? And then my pain also almost went from a 7, 8, 9, 10 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.
Male Host: And what about those around you? Because, as you say it’s very common and in your workplace as well.
Joe: Yeah, absolutely.
Male Host: You know, those messages are common. So how was it for you to break those posture rules in your social environment, your work environment, at the gym, etc?
Joe: I mean, it was very easy for me to break those rules because I just felt so good. Felt so good. I was going out of sight, I felt I was moving again. I was doing things I hadn’t done for years, and I was stoked.
So, I mean, it was very easy for me. But, I mean, I remember I was lifting in the gym one day, doing a really nice back deadlift. And you know, everything was nice and curvy and it was feeling great. And a boss of mine went past and he said, “geez, you’re going to do your back lifting like that.”
And I actually said to him, I said it’s actually funny you say that because this is the very sort of behaviour that’s helped me get over my back pain. And he just said, “well good.” But it’s amazing how prevalent that information out there is that you’ve got to lift with that really neutral spine.
Male Host: It’s big in gyms.
Joe: It’s big in gyms. It’s big in workplaces. I mean, it’s amazing as I said, it’s on every single delivery you get that’s over about 10kgs. If someone is in a picture, it’s someone picking it up using only their knees. Lift with your knees, not with your backs, you know?
Lift with your condition to lift and make sure you go through your range of motion. Yes, this is the advice that I would have given myself back then. But yeah, it was easy for me to break the rules, but I started getting more and more – I mean, at this stage I had a history of back pain and I was going to work still.
So, I mean, everyone knew that I had a bad back. Everyone knew that I had a bad back, it was three years earlier that I sort of hurt it. And it never came good. So everyone sort of knew. And so, when they saw me in the gym doing all these things, I got a lot of questions. 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 back pain.
There were so many people, and family members, friends, friends of friends. There are so many people dealing with this. It’s a huge problem, and all of them have the same beliefs. If I lift with a neutral spine, I’m less likely to damage my back.
Male Host: Yeah, right.
Joe: And then slowly the questions became more, oh wow you’re getting really fit. You’re getting really healthy, how? I mean God, I was getting asked for about the next 6 months, so how’s your back doing all that? It’s like, well, my backs really good. My back is about to be pretty normal.
And then slowly other people who knew I 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 someone. My problem isn’t your problem. So I would do this in consultation 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 they should be looking.
And, a lot of them have since had really effective treatment and back to being normal. I mean, I’ve got friends of mine, one of them in particular, I know he’s had an issue with back pain since he was about 20, and he’s almost 60 now. And I mean, he’s now absolutely living the dream. He’s killing it. He doesn’t have a problem anymore. And this is just, you know, all because he just sought the right help, and I guess, was willing to ditch his previously held beliefs.
Male Host: So, do you see those prevalent beliefs unhelpful, now if you look at it?
Joe: Yeah, absolutely. It’s massively unhelpful. I mean, we are conditioned from such a young age to think that our backs are fragile. And that we’ve got to protect them by keeping them straight. Especially when lifting or loading. And, I mean, it’s unfortunate, it’s just weird. I sort of, almost, I still look at that box and go down to – and I’m like, what the hell am I doing? It’s absolutely unhelpful.
Male Host: How hard do you think it will be to change that? It’s a question I ask myself every day. I reckon there would not be a person I would see who comes through my door – OK, well that’s not entirely true, but it’d be the absolute majority of the people I would see, who would seek help. Who would hold those views? Not everybody, but almost everybody.
Joe: Unfortunately, I mean, I think on an individual level, it’s very easy to reach, maybe easy is not the right word, but it’s possible, it’s doable, to reach an individual and in a one-on-one, you know, session, an appointment.
An hour-long, to get them to think about these things, and to change, but to change it, on, I mean – I don’t know the numbers, but there are millions, and millions, and millions, of people worldwide suffering from back pain. So, to change the message as a whole, I want to say, is an impossible task. I mean, I do know that there is a fair bit of resistance out there to change.
Male Host: Have you seen that yourself?
Joe: Oh, to a degree. But, I mean, a lot of the time when I’m talking to people it’s one-on-one, and they sort of go, well, these people that know me and trust me and they’re friends of mine. And so, they know where I was and where I am, and so it’s quite easy for me to talk. So I don’t see the issue with everyone.
I just 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.
Male Host: To help people one at a time when it’s, one of the problems we have is that it’s legislated.
That you have to educate people who are in manual jobs. Around ensuring they are lifting correctly. And, if we do a bit of the research we know that there’s not a single study that shows that teaching people how to lift better, so-called better, reduced back pain. But, it’s legislated.
Joe: I read some nonsense study about – because after I changed 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 then the tissue would break down, and they went, oh well the tissue there broke because you moved it in this dead spine. And that must be bad for you. But, I mean, if you did the same thing with any joint and a dead joint it would wear out if you used it. But that then doesn’t take into account the fact that we lay down new tissue. We’re living. So, oh god, I mean, it’s a nice jump if that’s where it all came from.
Oh, 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 thought, oh well, that must be bad.
Male Host: That’s right. I discussed that in Episode 4, quite in-depth actually. I kind of want to round it up with a couple of key take-homes for people at home.
In terms of posture, this whole idea you know, there’s the ergonomic industry when you go to any big office or workplace. There will be signs saying, this is how you want to sit. Keep your screen negative 10 degrees. Knees and hips at 90 degrees. Keep your feet straight. What are your thoughts about that?
Joe: Oh, look. I mean, it’s all quite funny, isn’t it? Whatever you do, you must not sit comfortably. You must be in a position of maximum discomfort. I don’t know, it just doesn’t make any sense.
I mean, we’re all so different. We’re different shapes. We’re different postures. We’re different in so many ways, and so the idea that there is an ideal sitting position for everyone just doesn’t make any sense. So, I would argue against it. If that got brought up then someone said to me, oh look, this is the way that you must sit, and that’s the best sitting position, I would argue for the negative.
Male Host: That one, that’s interesting. I’d love to just pick one little thing that 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 impact someone’s sleep, and a sleep-deprived person’s greater predisposition for pain, anxiety, worry, and fatigue.
You know, ill health generally. It’s such an important thing. What were your thoughts on posture and sleep?
Joe: So, I got told that sleeping on my back or side was better than sleeping on my stomach or my back. I always found it really comfortable, and I do now again, find it really comfortable sleeping on my stomach. It’s just how I’ve always slept, and that when I was going through my issues with the pain I changed because I wanted to have a more positive posture. So, I ended up sleeping on my side.
Made sure my hand was supporting my head so that was all straight. With a pillow between my knees because I heard that was a good thing to do for your back.
Male Host: So, it was just like your spine?
Joe: I was keeping my spine exactly the same way as I kept it for the 16 hours before. That was also exhausting. So, I just, even when I was sleeping.
Male Host: How was that to sleep?
Joe: I think that, I know of people that sleep like that. 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 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 correct sleeping position.
Male Host: Because the other thing that taps into is what we call vigilance. It’s like, constantly thinking about it.
Joe: Oh absolutely. I was worried that if I went into too deep of a sleep I might roll onto my stomach, and then screw my back up, right?
Male Host: OK, so that kind of constant thought of posture created a whole abnormal focus on your body. That became really unhelpful.
Joe: It just became a monster. Yeah, absolutely. So, two years ago when I was going, three years ago, when I was going through all of this –
Male Host: We’re laughing about it now, but it’s not funny.
Joe: It was, it was not funny at all. And, it’s had an absolutely terrible and detrimental effect on my life. My mental health, my job, my activities, everything. I was in a really, really horrible place.
I only laugh about it now, I guess, because just the ideas that I had around how I was going to help myself are the exact opposite of what ended up helping me. So, it was kind of weird. It’s a weird, comical irony which is why it’s kind of funny now.
Male Host: Exactly. Awesome. I want to summarise now with the whole idea of this one-size-fits-all. It’s what you sort of mentioned before. I think the other way to think of it, which I often use to rationalise 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.
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.
And you might sort of mention, to start, that you’ve always had terrible posture. I think it’s pretty safe to put that in quotation marks, and this is normal posture sounds, I mean, look at us, I’m kind of off-camera now but you know, that we like to vary our postures. We relax when we’re sitting, we get up and up and down frequently.
Joe: Yeah, if it’s comfortable, keep sitting there. And, then if it gets uncomfortable, we’ll go, oh that’s a bit uncomfortable, or that’s comfortable.
Male Host: That doesn’t mean that sitting up straight is 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 posture.
Joe: Yeah, that’s right.
Male Host: Cool, thanks, Joe.
Joe: Thank you.
Male Host: 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 Nic Saraceni has to say. A researcher and physiotherapist, whose whole PhD topic is on lifting, posture, and back pain.
We’re here with some researchers who are both researchers and clinicians. Nic, particularly, 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, related to lifting and low back pain?
Nic: Definitely for me, without a doubt, the most common misconception is that there is an optimal weight lift. That you should keep your back straight, and that you should bend your knees. 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.
Male Host: And what does the research tell us around what actually, you know, what advice would we give patients like this? So what is that fact, I suppose?
Nic: Well, part of my research is all about that exact question. We’re trying to figure out if there is an optimal lifting posture, and probably in a researchy kind of answer, there might not be. We don’t know if there’s an optimal lifting posture and definitely at this stage, not for everyone. So, the fact would be that at this stage we need more research in this space.
But, often it’s the opposite of what we think. When we looked at a review that we did most people actually with back pain were keeping their back straight up following that advice, 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 it, bending your knees more, is going to help everyone.
Male Host: Yeah sure. So that’s kind of talking to that ergonomic advice. In terms of, we often hear that people should be keeping their back straight, 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 labourers and manual workers, is there an association there with those occupations and having back pain?
Nic: So if you’re in a manual job, what the evidence would say is that, if you lift a lot, lift often, more than 25 times per day, and also if you lift heavy quite often, that you’re at greater risk. Your risk goes up as the heaviness goes up and the regularity of lifting goes up.
But, we’re not sure why. So, there is elevated risk slightly, 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. Maybe more than posture. Or, at least, you know, we don’t really know, but they might be just as important as posture. But yeah, you are at slightly greater risk.
Male Host: Yeah, sure. And is there kind of, we know that there are lots of ergonomic interventions, you know. There are programs out there that are teaching people how to lift. And, you know, how to position their spines correctly. What’s the evidence for those? Are they effective at reducing back pain?
Nic: In a short word, probably not. Short answer, probably not. Probably not.
Male Host: Is there any evidence for it, Nic? Had systematic reviews of ergonomic interventions to reduce the risk of back pain?
Nic: In summary, no, 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, to keep back straight and bend your knees. And that kind of ergonomic advice, it’s just not useful advice. So, yeah.
Male Host: So if you think of that though Nic, it would seem from your review and Nolan’s review that they are following the advice.
Nic: Yeah, true.
Male Host: So it sounds like option one probably isn’t the case. Because this idea of, well if they weren’t following the advice 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, Dave Nolan’s review 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. So it would suggest that actually, people with back pain revert back to the advice they’ve been given.
Nic: Right, yeah. Once they get back pain people are tending to follow that advice. 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 were no differences.
But once they get pain, people seem to revert to this advice. Where they keep their back straight and bend their knees, and obviously they’ve got pain doing that so it’s like you’re saying Pete, probably not that useful.
Male Host: So one of the things, I suppose I’d ask as 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? How much did they lift? How heavy were they? Did they lift a lot? Was it repeated lifting? Because you’ve said that your risk factors are heavy lifting and repeated lifting, what are those studies actually done?
Nic: So, they looked at up to 12kgs. Some of them were really light like a pen, but others were with weights of up to 12kg in a box. So that sort of encapsulates, you know, your regular occupational lifting, I suppose. But nothing heavy. So that was one limitation, it’s light lifting. And there’s a bunch of other limitations like, you know, how many they lift usually. There are only 3 lifts that they captured, right, so there were some weaknesses like you’re saying, too.
Male Host: That’s really capturing the risk in a sense, if you talk about heavy lifting, repeater lifting, 25 lifts minimum in a day, that is where the risk is. They’re not that research would suggest that there’s a bit of a jury out at the moment.
Nic: Definitely, the jury is 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.
Male Host: Yeah, we just don’t have the evidence at this stage. And a part of your PhD is trying to help answer that, obviously. 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.
Male Host: Yeah, and maybe you can give us a bit of a taster about, not of what you’ve found because it’s not published yet, but what your study has done to bridge some of the gaps in the existing literature.
Nic: Yeah, so some of the gaps 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 the other group that we recruited are still in lifting jobs but have difficulties with pain related to lifting.
So, we’ve captured groups like no other study has previously. Relevant cohorts that, and then tested them how they lifted. So, we got them to lift 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 captured that to try to address some of these limitations.
Male Host: And you used really accurate measurement tools, where I think some of the previous studies had, not all of them, but a number of them have pretty limited measurement tools. Look at accuracy, what was happening in the lower back?
Nic: Exactly. Yeah, we tried to capture curvature in a way where a lot of studies just looked at, you know, the whole trunk almost. So people think that curving the back is important. Previous studies didn’t look at that, we actually looked at, you know, what’s happening in the curvature component of it.
Male Host: So I’m interested, Nic, 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 hurt it lifting – how do you, kind of – and they say to you look, I don’t, I don’t want that again. It was a horrible event. How do I prevent it? Where does evidence sit now at the moment?
Nic: Sure. It’s a great question, and probably how I would go about it, if I put my clinical hat on, would be that I would ask that person questions around a whole number of factors.
Not just about how they lifted it, but to do with, you know, how often they’re lifting it, What’s been happening around the time of the onset of pain. Because what we know is that posture might be one part, but 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’s surrounding the context around when they got that pain.
And then I’d get them to demonstrate how they’re lifting. If lifting is still giving them trouble, I would look at how they’re lifting and then seeing 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.
Male Host: OK. 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 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, conditioning, etc. So it looks like there are other risks involved. The other part that, I think, it’s important that you highlight, is that someone’s risk of pain is multifactorial and so just focusing on one aspect of how you lift, maybe missing a bigger story. And so that exploration around that, at the moment we don’t have a lot of research evidence to say, you know, this is the way. We do have some evidence to suggest that there are more efficient ways to lift.
And that contradicts a lot of common beliefs that actually, you know, a round back lift looks like it’s more efficient in terms of the amount of load that you can generate. Force, you can generate in the body, but that again has to be explored further. I think one of the things that we look at, is people’s risk, which is the critical aspect of history taking.
But also no different to spraining an ankle. You would never tell someone with a sprained ankle never to invert their ankle again. You would say, look, for a period of time, just back 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.
I think that’s the story that often gets missed around backs, is that back’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?
Nic: I’d say so. It sounds like it’s pretty evidence packed.
Male Host: I know we’ve had a discussion about the issues around, you know, foot strike, for running. Around back posture, and foot posture. There was a whole rage around mid-foot running, or rearfoot 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.
Nic: Yep, and I think that it’s practical. Like saying to someone, you’re saying, keeping your back straight for every single lift doesn’t seem 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, it might be better than saying do it exactly like this every time. But, we have to test it I suppose.
Male Host: 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 probably one of the most feared activities, or bending and lifting. For people with back pain, 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 overprotect that area and overprotecting 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 building people’s confidence in their back to go back to lifting normally. 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 this. You’ve looked at survivors. People who’ve lifted in an industry for more than five years?
Nic: 5 years repetitively.
Male Host: And haven’t had back pain, so they will give us a bit of an insight into what a person who survives manual work looks like in terms of the way they go about doing that. That will be interesting, that’ll be interesting.
Nic: It will be answered shortly.
Male Host: Some common sense answers from us, from you both, which is great. I want to finish with, 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?
Male Host: Do you want to go first Nic?
Nic: 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 landscaper, you need to be strong and fit and healthy and capable to do that job so that that seems like a job you’re ready to do. You’re prepared for it. All that advice is for people without back pain as well, and I’ll say if you’re lifting in a way that doesn’t cause you any trouble I wouldn’t change that.
Whether that’s a curved 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.
Male Host: How 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 weekend and just go nuts in the garden and they’re not conditioned for it. And they hurt their back. And 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 ran 12k’s in the City to Surf and you said, it’s my knees and ankles. And so, we’ll go figure, you know, you’re not conditioned to run 12 k’s. You are not conditioned to do 500 repetitive bends, and heavy loads 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.
We know the body is an amazingly adaptable system and that we are good at doing things as long as we grade into it gradually. So, this idea of things being good or bad, I think it’s really unhelpful. This idea of being fit for the task, and I think you’ve touched on that, of getting people, you know – lifting is a wonderful way of keeping your back strong.
Before we had gyms we had gardens. Then we gave our gardens away and we got germs, so you know, it’s like that’s what we’re designed for. And you look at countries around the world, lifting and bending is part of our world. It’s something we should be encouraging people to have confidence in. I think it’s something that 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 look like it might be something that could be important for the health of any system. Joints, or you know, the spine. And caring for your whole health, that’d be the key. Things that we would look for.
But, in saying that, you know, we are human beings. We get pain. I get back pain very frequently but 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 you’ve got some serious pathology, sure you might have to lay off. But, for the majority of back pain, if you’re engaged with an 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.
My put out there for people who might be listening to this is that you know back pain can be scary, but it’s very rarely dangerous. 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 conditioned for the task.
Nic: 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 are 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.
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, and it happens all the time clinically, so you know, 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.
Male Host: And interestingly, you save that neck. Because from a clinical point of view if lifting is something that you avoid 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. We’re engaging with it as long as it’s done in a graded and sensible and safe way is the way to get back to it.
Male Host: Yeah, I think it’s a terribly important message as well. Often people think, oh if lifting is 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 I will make them better and more protective and less likely to have pain.
Male Host: 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, you 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 they can see sense in that.
It just doesn’t seem to be purely about posture. The only other thing 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 that’s probably the other most common thing I would say.
We did a research study a couple of years ago, so Emily Campbell and 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 you know, the 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 the common misconception there, I kind of described that as 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, 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 how I would look at it, and often we have to train people out of bracing their core. When they left I actually found 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 manual work. Is that it’s actually not smart to consciously engage, and that idea of having to 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 when we kick a ball or play a musical instrument or 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, fatigues you more, puts you on alert more, probably decreases your confidence in doing stuff and it certainly doesn’t improve your performance.
Nic: Yeah exactly. And Dave Nolan showed in his paper that actually, people who were in pain were tensing. People were stiffer and more co-contracted in their abdominals, more than the people without pain.
Male Host: Yeah, and the other way that I like to explain with patients is – we’ve got lots of cranes here in Melbourne at the moment. There are 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. 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’s not conducive to 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 sits.
In fact, your hamstring is probably a critical cable at the back end if you’re thinking of a crane. The other muscle group you want to get working, I would say, you’re doing lots of bending and lifting.
Male Host: Awesome, thanks, gents. Really appreciate your input. Thanks, Nic.
So there you have it. Another stellar episode. If your reaction to the previous posture episode is anything to go by, we’ll brace ourselves but not our cores.
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