Does Sitting Cause Low Back Pain?

Sitting And Low Back Pain

Sitting is the new smoking. – everyone

You’ve heard it. You’ve read it. Somewhere in your brain is the meme that sitting is the new smoking.

Yes, sitting for long periods without moving is unhealthy, mostly from a metabolic point of view, but does sitting cause low back pain?

In reality, like all things related to pain, it’s complex, and as a result, the research seems to be mixed, which is a far cry from what you’ll read in most health articles posted online, in newspapers and magazines.

What Does The Popular Media Say?

It’s really common for articles in the popular media, both online and offline, to say that sitting causes low back pain. (1,2)

Most say that the incidence of low back pain has increased because of increased sitting time or via mal-adaptive processes (like muscle shortening) as a consequence of sitting.

You will read about how sitting shortens hip flexors and hamstrings, about how sitting compresses the spine and the discs and about how sitting weakens “the core”.

Because these mechanisms sound plausible, and because they are repeated so often, they are gradually accepted as fact, without much further questioning.

Unfortunately, what makes sense in theory doesn’t always pan out to work in the real world, which is why we use the scientific method to try and determine cause and effect.

This is important for two reasons:

  1. If we determine that sitting causes or doesn’t cause low back pain, then we can act on this information accordingly.
  2. If we determine a causal relationship between sitting and low back pain, we can then look at why this might be happening, in order to better treat it.

What Does The Research Say?

When we look at the research around sitting and low back pain, the results are mixed.

One study (3) took a group in 1993 and followed up at 5 year intervals until 2012. They looked at mental health, metabolic health and musculoskeletal health. They found no association with occupational sitting and low back pain.

Another study (4) I looked at objectively measured sitting time as a risk factor for low back pain. This is important, because most studies rely on self-reported data, which is typically inaccurate. The authors found that total sitting time (most studies just measure occupational sitting time) was associated with low back pain intensity, when other factors were controlled for. This means that the more these people sat, the more intense low back pain they experienced.

The third study (5) I looked at wasn’t a study, it was a review. A review is when researchers look at all the studies on a certain topic that meet certain criteria, and then compile their results.

Aside: a meta-review is when researchers review all the reviews on a topic to get an idea of what “works”. This is regarded as the best form of research evidence, because it is more robust and has more statistical power (is more likely to be correct).

In this review the authors reached the following conclusions:

Although occupational physical activities are suspected of causing LBP, findings from the eight SR reports did not support this hypothesis. This may be related to insufficient or poor quality scientific literature, as well as the difficulty of establishing causation of LBP. These population-level findings do not preclude the possibility that individuals may attribute their LBP to specific occupational physical activities.

So as you can see, from my small sample, one showed a link, another showed no link and the review found no link, but also acknowledged potential issues as to why this is so.

So, Does Sitting Cause Low Back Pain?

As you can see, the results were not conclusive. Even if increased sitting time is associated with low back pain, it doesn’t mean it causes low back pain.

This is because, pain is emergent, not dependent.

An emergent property is a property which a collection or complex system has, but which the individual members do not have. A failure to realize that a property is emergent, or supervenient, leads to the fallacy of division.

What this means, is that pain arises based on many factors, that are unpredictable, so to try and isolate one variable, like sitting, as the cause, is impossible.

No one thing causes pain.

A “More” Plausible Explanation?

If we look at why somebody might experience pain after sitting, we have to ask:

Was it the sitting, or something the sitting did?

Do people who experience low back pain from sitting also experience low back pain from other activities?

What about positions that replicate sitting, but aren’t sitting?

If they do, then what do these activities have in common?

Finally, is there ways they can sit that don’t cause them pain?

Most of the time, we will find that sitting is not the sole cause of low back pain, and when it is apparently so, it’s likely that there are still other factors at play.

One way to explain why we get pain in certain positions, is to understand the sensitivity of peripheral nerves.

When we occupy any position, particularly when pressure on the body is involved (sitting, lying etc), there is a compression of body tissues taking place, including the peripheral nerves.

When we apply pressure to peripheral nerves, they deform.

This deformation causes altered neural blood flow – rabbit models show a reduction of up to 70% of their blood flow when a strain of only 8.8% is applied.(6)

This could feasibly be a driver of nociception (bearing in mind that pain is produced by the brain, there are no “pain signals”) which could result in a pain experience.

So instead of thinking that sitting causes low back pain, it is probably better to look at the function of your body as to why you don’t have the capacity to sit for extended periods, and address those issues.


Just because sitting doesn’t necessarily cause low back pain, doesn’t make it harmless. Sitting has many pronounced negative effects on our metabolic functions, and movement has many pronounced benefits, including reduced incidences of pain (7).

Additionally, if you understand that no one thing causes pain, you will be in a much better position to deal with pain when it happens.


This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




(1) Heal your lower back pain with these 5 yoga poses

(2) Proper sitting

(3) Occupation sitting and cardiometabolic, mental and musculoskeletal health

(4) Sitting time (measured) and low back pain

(5) Occupational physical activity and low back pain

(6) Structure and biomechanics of nerves

(7) Physical activity and chronic pain (in mice)

Why Mobility Exercises Don’t Work, And What To Do Instead

Man with great mobility doing yoga with laptop

You don’t wake up one day suddenly stiff, it only feels like that.

Mobility, like most skills, exists on a “use it or lose” basis.

Unfortunately, for most of us adults, our daily lives don’t incorporate much “using it”, so we end up “losing it”.

The best way to maintain mobility if your life doesn’t have you climbing trees and crawling around on a daily basis is through exercise, but, if you have already lost a large amount of mobility, then you’ll have to work specifically to regain it, exercise alone is often not enough.

If you ask google “how to increase mobility”, the top 5 results say roughly the same thing: stretch, foam roll, perform dynamic “joint mobility” and “activation” exercises.

These are valid, but incomplete strategies.

The reason being, lack of mobility is usually not a true range of motion issue – I could lie you down on a treatment table and passively move your joints through a much greater range of motion than you can demonstrate – but rather, a stability issue.

Instability is perceived as a threat by the central nervous system, so protectively, it shuts down range of motion so you can’t cause yourself any harm.

Thus, the underlying cause of limited mobility is neurological.

So, in order to improve mobility in the real world, you must go deeper than foam rolling and targeted stretching/joint exercises and “release the brakes”.

If you don’t, you will just end up spinning your wheels, because when improperly applied, mobility exercises don’t work.

This is because you can’t force the body to do anything, it will resist in an effort to maintain equilibrium.

Now, there are definitely cases where there are physical changes to soft tissues and joint structures that limit mobility, but, outside of diseases and trauma, these physical changes usually occur as a result of the limited mobility caused by the nervous system (use or lose it principle).

So, if you have lost mobility over time, how do you get it back? There are many ways, this is the process I’ve found effective and use with my patients:

Osteopathic Manual Therapy

Being an osteopath, I like to start with manual therapy, but not for the reasons you might think.

Manual therapy doesn’t change tissue length, nor does it “put you back into place” or “re-align” you.

What manual can do, and in the hands of a skilled practitioner, does very well, is provide the body with a chance to change.

Movement, or motor output, is the result of complex co-ordination that takes place in the brain, based in part, on sensory information provided by the peripheral nervous system.

Nociception, the transmission of “danger” signals to the brain and spinal cord from nerves located throughout the body can inhibit motor output.

Nociception is related to, but not the same as, pain. You probably know that if something hurts, it usually doesn’t work well. This can also happen when that something doesn’t necessarily hurt, but the nerves are hyper-active anyway.

Because the body functions as a whole, when one area isn’t moving properly as a result of this increased nociception, then there is a chain reaction throughout the rest of the body.

By using manual therapy, we can inhibit nociception, change motor output and affect a change throughout the rest of the body – often decreasing pain and increasing mobility.

Often manual therapy alone is enough, especially if the issue is relatively new or minor, and new, dysfunctional patterns have not had time to become ingrained. If the problem has been around longer, or is not responding to manual therapy alone, we can move to the next step.

Restore Reflexive Stability

Reflexive stability is the term physiologists give to the near instantaneous adjustments that take place when we move.

This allows us to move safely and effectively, and usually efficiently.

With disuse and pain, this response is dulled, and one of the results is an increase in stiffness, which is designed to protect us in the absence of true stability.

To restore this, you have to go back to fundamental movement patterns, progressing to the next only when you have reached mastery each position/stage.

As mentioned earlier, most stiffness is the result of instability, rather than a true range of motion issue. With this in mind, regaining lost reflexive stability is an effective way to improve mobility by addressing the underlying cause.

Reflexive stability exercises are by nature, whole body movements, performed in progressively more challenging positions/postures.

For the vast majority of people, a combination of manual therapy and reflexive stability exercises will improve most mobility deficits.

For an example of reflexive stability in action, try this simple test:

Perform a squat, noting your depth and the amount of tension involved in achieving it.

Now, get down on your hands and knees and perform 60 seconds of quadruped rocking (below):

After 60 seconds, get up and retest your squat.

If you notice an improvement, then you just witnessed the benefits of reflexive stability. If it was the same for you, then either you don’t have a deficit, or your deficit is elsewhere.

Maintaining Reflexive Stability

After you have gone through the progressions, moving from ground based to upright, the easiest way to maintain your reflexive stability and build your health is by walking properly and walking regularly.

Walking is largely reflexive – a lot of the control occurs at a spinal, not brain level – which means that once you have restored your reflexes, maintaining them simply requires using them.

Now, any old shuffle won’t do, what you want in order to reap the benefits, is to walk with a contra-lateral arm swing, looking up. Ambling down the street with your phone in your hand and your eyes on your phone isn’t going to help you, it’s only going to re-inforce the issues the caused you stiffness in the first place.

For most people, especially those of you who don’t exercise, these two steps alone are enough to restore the mobility you need to go about your daily living.

If you are exercising and/or you want to take things even further, then we can add a few more steps.

Active Stretching and Functional Movement

If you have addressed potential issues with manual therapy and general (reflexive) stability work, but you’re still not getting the specific mobility improvements you want, it is time to begin more targeted work.

One form of targeted mobility work I like to use is “active stretching”.

Active stretching is probably just another name for PNF (Proprioceptive Neuromuscular Facilitation) stretching, but it’s simpler for my patients to understand, so I prefer that.

Active stretching is where you are stretching a muscle group whilst simultaneously activating opposing or synergistic muscle groups – essentially adding stability to the newly explored range of motion.

I’ve found this to be far more effective than passive static stretching, and it really helps people “get” what a joint position is supposed to feel like.

If you then use this increased joint range of motion in more demanding, functional tasks, then you “teach” the body that this range is okay to use, because you are adding strength/stability to a previously weak/unstable position.

This results in an increase in mobility.

In the following example I shared on Instagram, I’m using an active hip flexor stretch, followed by an isolated glute activation exercise before reinforcing the new pattern under load with a barbell squat:

If the problem was at the ankle instead/as well as at the hips, another sequence might involve an active calf stretch (demonstrated below), followed by a dynamic mobilisation of the ankle joint before squatting.

Again, these exercises are not only addressing range/length of a joint/tissue, but improving stability, which, as we discussed, is often the real driver of joint mobility.

The functional exercise then reinforces the pattern, and once repeated enough times, in correct fashion, it is usually enough on its own to maintain the improvements in mobility.

Whilst I demonstrated the example with a barbell squat, this isn’t necessary, you might simply perform a full squat position, as millions of people around the world do on a daily basis, in order to maintain mobility.

As always, the execution will depend on your needs and wants, but the underlying principles remain the same.

An Aside On Exercise Technique

In the examples above, the active stretching is then reinforced by the high demands imposed by the squat.

However, if you are squatting with poor form, then you are undoing the effects of the active stretching.

Good form is easy to spot – it is controlled, stable and smooth. Whilst everyone has different body shapes and sizes, thus the execution of movements will look different, the ability to perform controlled movement should be universal.

It’s also important to understand that if you skip straight to exercise, without addressing the stability issues first, then your body will simply “survive” the exercise by using whatever movement pattern is strongest, optimal or not.

Once you have addressed these issues, using optimal exercise technique reduces the need for continuing mobility work – once you’ve got it, maintaining it is easy – this is why in countries where people continue to squat throughout their life, mobility deficits are less common.

Maintaining Mobility

Maintaining mobility is relatively simple: use what you have got.

If you are coming to this article with restrictions, then it is still simple: regain what you’ve lost, then use it to keep it.

If you go to all the effort and expense of getting treatment and performing the work to regain mobility, only to continue with the lifestyle that got you needing treatment in the first place, then chances are, you’ll end up back where you started, given a long enough time frame.

Because we don’t have many (any) physical demands to survive anymore, we have to deliberately perform tasks that challenge us physically, including our range of motion.

This goes against human nature, which is to conserve as much of our energy as possible – it’s wired into our brains to do this – so, what I recommend is to build mobility maintaining activities into your day.

Examples of mobility maintaining activities are:

  • Walking properly (as discussed earlier) instead of driving short distances
  • Sitting on the floor to watch TV instead of on a couch
  • Squatting instead of bending to pick things up from the ground

Whilst these activities are not going to prepare you for a Cirque de Soleil audition, they will help with your activities of daily living (ADL) and your quality of life.

Beyond this, exercise, particularly full range of motion strength training, in all its forms, is the best way to maintain, and even improve mobility.


Mobility exercises need to be used in context. If you use them when you have an underlying stability issue, either at the stiff segment or elsewhere in the body, they will not be effective.

Used in a sensible, principle based approach, like the one I outlined above, they can play a valuable role in regaining mobility.

Once you have restored lost mobility, it’s much easier to maintain. This can be done by incorporating activities into your day that require you to use extra mobility.

Walking is one of the best general exercises, if you do it well, and can help maintain good health, including mobility.

For more focused efforts, full range of motion strength training is probably the best way to maintain and even improve joint mobility, once you are moving correctly.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




Nociception and motor function

Cutaneous afferent regulation of motor control

Feed forward control and movement stability

Physiological basis of functional joint stability

Training the Core

Lower motor function, Lederman, E., The Science and Practice of Manual Therapy, pp 99-100

Osteopathy for Headaches and Migraines

Woman with headache

Chronic headache is the most common neurological complaint presenting to GPs in Australia. (1)

This means it’s likely to be even more widespread than statistics suggest, as many people simply don’t seek medical treatment for chronic pain conditions.

So it’s safe to say, headaches and migraines are kind of a big deal.

Most people experience headache at some point in their life. If it is simply a one off, or infrequent, then most of the time, the best management involves either putting up with it, taking simple over the counter analgaesics or getting treatment from an osteopath (or similar).

However, when headaches are persistent, more targeted management is needed, and the first step is identifying the type of headache you have, which will influence the type of treatment accordingly.

Types of Headache

When it comes to headaches and migraines, there are two broad categories:

  1. Primary headaches, which the headache is the problem itself. These include migraine, tension type headache, cluster headache and other (less common) primary headaches.
  2. Secondary headaches, where the headache is a symptom of an underlying condition, including meningitis, brain tumours, aneurysms and brain bleeds. (2)

Because of the serious nature of the underlying conditions that cause secondary headaches, new headaches, particularly very intense or persistent ones, and those with other neurological symptoms like nausea, dizziness, visual changes and loss of balance should be examined by a medical professional.

This post will look at primary headaches and migraines, to give an understanding of the physiology involved as well as treatment options and self-management strategies.

The Headache Continuum

Primary headaches account for 90% of headaches, and are a common cause of visits to health professionals, including osteopaths.

The two most common form of primary headache are migraines and the tension type headache.

Understanding the difference between the two will help identify appropriate management strategies, so an accurate diagnosis is imperative (this means seeking out someone who went to university and studied medicine, not someone who watched an episode of House and wrote in an online forum).

A helpful way to understand the differences between tension type headaches and migraines is by the use of a continuum (3).

Health professionals love a good continuum, and I’m no exception. In the case of headaches, we have migraines on the far left and tension type headaches on the far right.

Headache-Migraine Continuum

In terms of the continuum, we have neuro-vascular involvement (migraines) at one end, and psycho-neuro-muscular involvement at the other (tension type headaches).

Though not officially recognised by the International Headache Society (IHS), there tends to be an agreeance amongst many clinicians and academics of the existence of mixed type headaches as well, which would exist about halfway along the continuum.

Finally, for this post, we will consider cervicogenic headaches, as commonly diagnosed by osteopaths and physical therapists, as well as GPs, to be similar to tension type headaches, in that the clinical features and physiology underpinning them is quite similar.


Migraines are typically intense headaches that can last up to 3 days, often accompanied by other neurological symptoms such as photophobia (sensitivity to light) and dizziness. There are two main types of migraine – those with an aura and those without.

Migraines involve the activation of, or the perception of, the activation of the pain-producing innvervation (nerve supply) of the cranial blood vessels. (4)

Diagnosing migraines comes down to a careful history.

As migraines involve a heightened sensitivity to change in stimulus, with a careful history, often triggers can be identified and managed.

Although this is a tedius process, for those sufferers who can identify specific triggers through a process of elimination, managing migraines with lifestyle changes becomes a whole lot more viable.

In addition to lifestyle changes, there are medications which are effective in both the management of acute migraine and in the prevention/reduction of chronic migraine.

For acute migraines, one of the most effective interventions is to take 900 mg of aspirin along with 1000 mg paracetamol. (5)

In some people, NSAIDs (Naproxen, Ibuprofen etc) will have a better effect.

In many cases, there are more specific medications that will work better than those listed, though the list is long-ish, so it might take some trial and error to find out the specific medication and dosage that works for you. Again, work with your doctor, not a blog, to figure out the best approach for you.

Please understand, all medications (in fact, all interventions) have potential side effects, so before you go taking any medications, get medical advice.

Tension Type Headaches

Tension type headaches are mostly diagnosed on an exclusion basis – that is, they don’t have particular features that would classify them as another type of headache. They are the most prevalent form of headache, but often go untreated, as people don’t seek out assistance for them.

The specific patho-physiology of tension-type headaches isn’t clearly understood, but the name implies some form of mental or physical tension involvement, which is agreed upon by headache researchers.

The reason they exist at the opposite end of the continuum to migraines is the absence of vascular involvement. (6)

It is most important to get an accurate diagnosis, as these headaches, are quite a clinical challenge to treat. So if you actually suffer from migraines, but get diagnosed as suffering from tension type headaches, you are potentially missing out on efficacious treatments.

Many people with tension type headaches experience exacerbation in times of psychological or physical stress.

If this is you, pro-actively managing your stress is one of the best preventative treatments available.

Additionally, tension type headaches often have a muscular component – that is, physical tension produced by overactive muscles, usually across the face, head and neck.

Osteopathy For Headaches and Migraines

What is interesting about headaches, is that, in terms of nerve supply, facial and cranial areas are all supplied by the trigeminal nucleus.

So although the cause may differ between a migraine and a tension type headache, the origin, may be the same.

This is clinically significant, because the trigeminal nucleus blends with the nerves from C1, C2 and C3 (the upper part of the neck).

This means that treatment to influence these nerves, can, theoretically, influence all kinds of headache.

Unfortunately, theory doesn’t always translate to practice, but many osteopathic techniques to treat this area relatively safe and risk free, with the big exception being techniques that involve end range rotation of the neck, thus it may be worth exploring.

Additionally, for most people, osteopathic treatment can help relieve some of the systemic effects of headache, including an increased stress response and muscular tension.

Some of these systemic effects include:

            • Sympathetic inhibition via rib raising. The sympathetic nervous system is involved in the stress response, including blood vessel dilation/constriction, which can potentially affect migraines. (7)
            • Parasympathetic stimulation via manual therapy and breathing exercises (see the image below). The parasympathetic nervous system counteracts the sympathetic nervous system, and stimulation is involved relaxation and recovery from many stress mediated conditions. (8,9)

Take a deep breath.Chances are you’re not aware how breathing can improve your health and wellbeing (beyond keeping…

Posted by Integrative Osteopathy on Monday, 8 February 2016

These manual techniques can be quite effective, however, as previously mentioned, it is important to “treat the person, not the headache” and consider psycho-social variables as well.

An osteopath can help you recognise and deal with particular triggers of migraines or your response to stressors that might be contributing to your tension type headache and if there is further management required, an osteopath will work alongside your “health team” which may include your GP, neurologist and possibly a psychologist to optimise your management.

What Can You Do For A Headache?

Best practice for the treatment of painful conditions involves what is term an “active approach“, that is, an approach where you are engaged in you care and actively participating to achieve a result.

i.e. “doing something”, as opposed to merely showing up and receiving treatment passively, or having something “done to you”.

This means, if you are suffering from headaches you can definitely do a few things that may help relieve or reduce the incidence:

                          • Educate yourself. Understanding a problem can help you deal with it better. Understanding alone doesn’t seem to improve pain outcomes, but when combined with other active therapies (as listed below) and incorporated into your medical management, it makes a big difference.
                          • Increase your physical activity. If you don’t meet the guidelines (>30 mins daily of moderate activity), then increasing your activity by walking more will have general health benefits that may improve your headaches.
                          • Practice mindfulness. Mindfulness helps you deal with stressful situations better. It also “strengthens” your brain, building neural links that are often negatively impacted with pain.
                          • Sleep better. Improve your sleep hygiene – take electronic devices out of your room, use black out curtains and keep the room slightly cooler than the rest of the house. Additionally, build a bed time routine so that you fall asleep more easily. Fatigue can increase neural sensitivity, and the only way to combat fatigue is with adequate high quality sleep.
                          • Talk to people. Chronic pain, including headaches, can be quite debilitating, as well as isolating. Talking to others who suffer from headaches/migraines in support groups, or a professional counsellor can help with some of the negative thoughts and feelings that develop around pain and often times make it worse.

The best thing about all of these things, are that they are either free, easy to do or both.


Headaches are debilitating, yet with a proper diagnosis, treatment and management is possible.

This treatment must incorporate biological (physical) as well as psycho-social factors.

Looking at the research on osteopathy/manual therapy and headaches, it can seem that often times “nothing much can be done about them”.

However, when you look at physiological plausible mechanisms of treatment, and apply these to both the causes and origins of headaches, the picture seems more promising.

As always, there is no holy grail, and getting on top of things takes a team effort between yourself and your practitioner(s).

Additionally, there is much you can do for yourself, which, while it may not be “headache specific” can greatly improve your health, wellbeing and potentially your headaches.


This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




(1,2, 3) RACGP – Management of Chronic Headache

(4,5,6) Wall and Melzack’s Textbook of Pain

(7) Rib raising and autonomic activity –

(8) Osteopathic Manipulative Therapy and HRV – unpublished research from London School of Osteopathy

(9) Deep breathing, pain and autonomic activity –

(10) Relationship between rcpm and dura –


Rethink Pain: Osteoarthritis

Knee X-ray

In the first post of the Rethink Pain series, Moving Beyond Muscles and Bones, we discussed shifting your view of pain away from body tissues like muscles and bones towards a more accurate one, of pain as a protective neurological process.

This post will take that concept and apply it to one of the most prevalent and debilitating chronic conditions in the world today, arthritis.

Nearly everyone has heard of arthritis. Arthritis is actually a group of conditions that affect the joints, encompassing a variety of conditions from autoimmune to inflammatory. This post is going to focus on the most common form, osteoarthritis (OA). 

There is a lot of misinformation surrounding arthritis, spread by cultural memes and well meaning family and friends. This leads to erroneous thinking that is likely causing a nocebo effect (the opposite of the placebo effect).

What is Osteoarthritis?

Described as “wear and tear”, osteoarthritis is, more correctly, a condition of joint cartilage degradation and reactive bone growth.

Cartilage covers the surface of most of our movable joints, creating a smooth and gliding surface, as well as providing shock absorption.

Tissues are constantly being “broken down” and then “rebuilt” in our bodies. This is a completely normal process which allows us to grow, heal and adapt.

When someone has osteoarthritis, this rate of degradation is accelerated and not matched by an increase in the rate of cartilage regeneration.

Here’s a simple analogy:

Imagine you are spending $1000 per week and making $25 per hour. To break even, you must work 40 hours.

Next, imagine after a few years your spending increased to $1250, yet you are still making $25 per hour – you now have to work 50 hours per week to cover your costs.

A few more years pass, and your spending increases yet again, lets say to $1500 per week. This time, however, your hourly wage drops to $20 per hour – you now have to work 75 hours to break even.

Eventually, if this process continues you will not be able to keep up. This is similar to what happens in OA – the rate of cartilage regeneration cannot keep up with the rate of degradation.

What Causes Arthritis?

There is no singular causal factor for arthritis. There is a large genetic component along with the combination of other factors (1).

Some of these factors include:

  • Tissue susceptibility/genetics. Cartilage is slow regenerating tissue at best, due to both is structure and its low blood supply. Some people have slower regenerative rates or are more susceptible to increased degradation.
  • Aging. Rates of regeneration decrease as we age, arthritis is more common in older people, and we have an aging population.
  • Chronic systemic stress. Stress hormones are catabolic – they increase tissue breakdown. Stress levels seem to be higher these days, as a result of both economic and cultural/lifestyle changes taking place across the globe.
  • Obesity. People are heavier, on average, and obesity has a correlation to arthritis via two mechanisms: increased mechanical stress on joints and increased inflammatory mediators in the bloodstream (secreted by fat cells).
  • Mechanical stress/”overuse”. We’ll discuss this further below, as “wear and tear” or “overuse” is one of the most common throwaway descriptions of arthritis.

One factor that’s often cited by medical/health practitioners is mechanical stress, commonly termed overuse or wear and tear.

There are a few problems with this language.

First, what is overuse, and how do we measure it?

Second, it doesn’t take into account that different ways of using your body have different effects.

In the case of arthritis, full range of motion through the joints stimulates cells called synovites, which secrete joint fluid to provide nutrition and have a protective effect on the joints.

Limited and repetitive range of motion activities tend to create uneven joint stresses, causing reactive bone growth, and an increased firing of the nerves, which affects joint mechanics and can increase sensitivity and pain.

So yes, certain activities can increase the likelihood of arthritis in susceptible people, but simply using your body does not cause arthritis. This has been demonstrated in runners (2), for example, who have no more arthritis than non runners, despite the myth that “running is bad for your knees”.

 Arthritis Pain

The biggest problem with arthritis is the associated pain. Most people don’t consult a doctor or allied health professional for anything else related to arthritis.

Pain doesn’t correlate well with imaging findings or the severity of joint degradation (my emphasis):

Patients largely present with pain and disability after significant loss of cartilage has occurred, but it is estimated that up to 40% of individuals with radiological damage have no pain. (3)

This kind of blows the “damage causes pain” thought process out the window, doesn’t it?

So how might this be?

Pain is a perception created by our brains in response to a variety of different sensory “inputs” including:

  • “Danger signals” from peripheral nerves in joints, muscles and other body tissues
  • Thoughts and expectations
  • Emotions
  • Brain and body chemistry – for example, hormonal status

We can divide these into central factors (brain and spinal cord related) and peripheral factors (everything else).

One of the most important central factors is called sensitisation. Basically, this means that the spinal cord and brain become more sensitive and produce pain in response to less and less stimuli.

This mechanism is proposed to be largely involved in arthritis related pain.

This then triggers a positive feedback loop whereby the pain causes negative emotions, reduction or avoidance of movement and an increase in stress hormones which then further aggravates the pain.

An example of a positive feedback loop between pain, cognition and emotions.

An example of a positive feedback loop between pain, cognition and emotions.

In addition to the central factors described above, there are peripheral factors that likely contribute to arthritis pain as well.

Some of these peripheral factors would include:

  • Impaired fluid dynamics of the joint
  • Inflammation
  • Mechanical strain

All these factors would likely increase the frequency and intensity of nociception, the transmission of “danger signals” from the nerves in the joints, causing the brain to produce a protective response of pain and stiffness.

If this cycle continues for long enough, then the peripheral nerves can also become sensitised, leading them to start firing at lower thresholds, much in the way central sensitisation works.

For a more in depth understanding of these processes, read Pain Science BasicsIt describes in easy to understand detail what is actually happening when we experience pain.

Osteopathy For Arthritis

The osteopath’s way of thinking is to look backwards from the presenting symptoms to try to work out why the body would “adapt” in such a way.

In the case of osteoarthritis, we would want to know the answer to the following questions:

  1. What has lead to the increased rate of cartilage degeneration in this person, in this joint?
  2. What has lead to a decrease in the rate of cartilage regeneration in this person?
  3. What potential factors may be contributing to this person’s pain?

As a result of these questions, two different people with knee osteoarthritis may end up with differing treatments, based on their primary causative factors.

Of course, the disease process is common, so there will be a lot of overlap, but treatment will always be tailored to your individual’s needs.

If you were suffering from OA and came for treatment, we would want you to feel a part of the process and be engaged in your care.

This means we’d place a large emphasis on educating you so that you fully understand what is happening, why it is happening and the implications for your life presently and in the future.

We would also present you with your treatment options, their risk, benefits, cost and the likely results of not doing anything.

We would then, use manual therapy to mobilise the entire body. Why the entire body? For starters, if your osteoarthritis is the result of, in part, altered biomechanics, treating the entire body is the only way to restore balance.

You see, whilst there may be altered loading of the affected joint(s), this may be the result of a protective response by the nervous system resulting from adverse tension elsewhere, in other words, your body is compensating for another issue.

Additionally, it is important to recognise that separation of the body exists only in our minds. Our knees are served by the same organs that serve our shoulders and everything is integrated by the one brain. This means it only makes sense to treat the entire body – we are, after all, not body parts, but people.

Our osteopathic treatment for osteoarthritis is gentle, slow and rhythmic, allowing for the body to self correct with movement/relaxation of muscle and joint tension, all the while helping with fluid dynamics throughout the body. It shouldn’t be painful, as we don’t want to increase any sensitisation that may be present.

Further, in addition to manual osteopathic techniques, we would show you how to manage or improve your condition with lifestyle changes, which we will discuss further below.

What Can You Do To Help Yourself?

Although genetic predisposition can play a large role in the development of OA, for most people, it is complex interaction between genetics and environment that leads to the onset of physical changes to the affected joint(s), and an even more complex interaction that leads to the onset of pain.

With this in mind, you can definitely take action to help prevent/delay/manage the onset of osteoarthritis in your life.

Things that you can do include:

Maintain an optimal body weight for your frame

Every body is different. Some people have a large skeletal frame, others are more compact. Some people are naturally lean, others tend to carry more body fat.

What is undeniable, however, is that from a medical point of view, there is an optimal weight range for your frame.

At this weight, you are not so big that there is increased stress on your joints and organs, but not so small you compromise your lean body mass and hormones.

In terms of osteoarthritis, increased weight, as mentioned earlier, is a risk factor both biomechanically and chemically as a result of increased systemic inflammation.

The BMI is a good general guide to maintaining a healthy weight, but it does not take into account body composition (muscle vs fat), only total body weight.

Waist measurements are another good guide to whether you are storing a lot of risky visceral fat (the fat that sits on your organs and leads to conditions like diabetes and heart disease).

If you are overweight, it’s a good idea to speak to your doctor as a starting point, to get blood work done and then any referrals you need to other health professionals who specialise in weight loss, because, aside from OA, there are many other health conditions made worse by being over weight.

Lead an active lifestyle

Some people love to exercise, others don’t. That is completely fine.

Leading an active lifestyle doesn’t mean you must spend hours every week in the gym or running the streets. If you don’t like exercising, and you otherwise have a sedentary lifestyle, it is in your interests to increase your activity levels.

This could be as simple as walking or cycling more as a means of transport.

Incorporating some form of work with resistance is also important for health, again, if you don’t like the gym, this could be doing physical work in the garden or around the house that involves lifting, pushing and pulling.

Now, if you are suffering from OA pain, this can be hard to do, so as always, prevention is better than cure. However, there are generally ways you can increase your activity, even with OA.

Live with purpose

As humans, we need meaning in our lives. This meaning, or purpose, gives us reason to get out of bed a do things each day. Without it, we waste away, mentally and physically.

Everyone will have different things that give them meaning, this doesn’t matter, it’s what makes us great. What does matter, is living with purpose.

Research is unequivocal – those who live with purpose have longer and healthier lives in almost every meaningful measure, including pain.

Maintain strong social networks

Whether you have a huge family or a strong network of good friends and acquaintances, maintaining social ties is not only linked to better health and wellbeing, but less pain.

Whilst living in pain can feel isolating, living without social contact is quite bad for us in both the long and short terms.

One study showed that adolescents in isolation demonstrated increased levels on inflammatory mediators in their blood, which affected their physiology for their entire lifespan! (6)

Open up to your existing friends and family more, reach out to those you’ve lost contact with and get engaged with like minded people to make more connections.

The internet has make connecting so much easier, but staring at a social network on a screen does not replace face to face interaction.

Increase Your “Physiological Buffer Zone”

The physiological buffer zone is a concept described by Patrick Ward, MS, an American sports scientist currently working with the Seattle Sounders FC.

In simple terms, it is basically the buffer you have between physiological stress and the onset of injuries and symptoms.

To increase this, an analysis of your physical status is required and then a prescription of exercise, lifestyle, nutritional and recovery advice is given, aiming to improve your resilience.

Whilst this concept was developed for athletes, it is certainly applicable to everyday people with everyday pain.


Medications to help manage arthritis pain do exist, but most are not very effective. Some relief can be expected, but it is very rare for medications to provide complete relief from osteoarthritis pain.

One medication that seems to be promising, is topical capsaicin. Capsaicin is the active ingredient in chillies. Extracts in topical creams stimulate particular nerves that have been shown to decrease pain. (8) The promise with capsaicin is that the side effects are quite minimal, unlike other many other common medications used to manage osteoarthritis pain.

You should consult your doctor for options about medications, asking about their effectiveness along with their side effects.


Osteoarthritis is a multi-factorial condition that affects a large number of people. By far the most common complaint is pain, which doesn’t seem to be directly caused by the extent of joint changes, but rather by increased sensitivity, both centrally and within the joints.

In general, the best way to treat/manage osteoarthritis long term is to strive to improve your health in all aspects whilst utilising specific treatments to reduce your pain and other symptoms.

Together with right environmental factors, you give yourself the best chance to lead a full life.

If you suffer from OA and would like to add anything, we’d love to hear your story in the comments below.


This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




(1) Kumar, et al, Robbins and Cotran Pathologic Basis of Disease,  Elsevier Saunders, 2005, PA

(2) Running and osteoarthritis:

(3) What makes osteoarthritis painful?:

(4) Positive feedback loop in pain :

(5) Obesity and arthritis:

(6) Obesity and arthritis:

(7) Social networks and long term health:

(8) Social networks and pain:

(9) Topical capsaicin for pain:

Osteopathy For Low Back Pain

Low Back Pain

Low back pain is extremely prevalent across society (1,2), and one of the most common reasons people consult with an osteopath in Australia.

Unfortunately, whilst there are many published suggestions that low back pain is self-limiting, often this is just a repeated cycle of aggravation and remission (3), and thus professional management is required.

The good news is, that with appropriate management, there is a good prognosis for both the short and long term.

Most manual therapists like to say they “treat the cause and not the symptoms” of low back pain. Unfortunately, we know low back seldom has a singular cause.

My way around this is to use a modifiable system, in order to address the main factors involved with low back pain.

  1. Assess – basically, we want to work out what you can and can’t do.
  2. Educate and empower – I want you to know what’s going on, and what we can do about it
  3. Alleviate pain and discomfort – this goes without saying
  4. Restore function – absence of pain is not function
  5. Build resilience – mentally and physically, so it doesn’t happen again

This approach to treatment is further tailored to each individual based on their risk profile, personality and individual preferences.

This means, that you get the benefits of a systematic approach, ensuring your outcomes are more predictable and that nothing is missed along the way, combined with the individualisation of care, making your treatment, your treatment.

Types of Low Back Pain

Simply put, we can group low back pain into 4 main types:

  1. Acute low back pain with no lower extremity symptoms
  2. Acute low back pain with lower extremity symptoms
  3. Chronic low back pain with no lower extremity symptoms
  4. Chronic low back pain with lower extremity symptoms


No matter what the tissue diagnosis is, these 4 groups of low back pain typically behave and respond in similar ways.

So, instead of getting caught up in whether you have a disc injury, a muscle strain or joint sprain, focus on which group you are in, and what stage of recovery you are at.

A process based approach to recovery, Eyal Lederman, PhD.

A process based approach to recovery, Eyal Lederman, PhD.

Then, you can focus your treatment on enhancing that stage of recovery.

We can do this, because we know that each aspect of low back pain has generalised features that occur as part of the pain response.

General Features of Low Back Pain

The general features of low back pain are, more accurately, general features of pain, as to an extent, they occcur with the majority of different musculoskeletal pain.

Stress Response

Pain is part of a threat response system.

Our nervous system is highly evolved, albeit sensitive, and pain is designed to alert us to possible danger.

When we experience pain, we also experience an increase in sympathetic nervous system (fight/flight) activity.

Some of the effects are elevation of stress hormones, an increase in heart rate, decreased visceral blood flow and “narrowed” thinking.

This stress response is important in the short term, as it allows us to “get to safety”. In the long term, it is an impediment to healing.

Osteopathy, in the form of a generalised whole body treatment can stimulate the parasympathetic nervous system (rest and recover), alleviating the stress response and accelerating recovery. (4)

Changes To Local Muscle Tone

As part of the threat response, our brains increase the tone of certain muscles, as a protective measure.

The increased tone of our muscles is the way our brains “brace” the area.

Unfortunately, beyond the very early stages of the pain response, this increased tone will often inhibit movement, which is actually helpful to the recovery process.

Osteopathic treatment can change this tone by affecting neural receptors in the skin, muscles, tendons and joints.

Impaired Motor Control, aka, You Can’t Move Normally

Nociception is the transmission of “danger” signals from peripheral nerves, called nociceptors.

Fast acting or slow conducting nociceptors transmit to the spinal cord. This is the primary driver of pain in the majority of cases.

Nociception affects motor control. Have you ever stepped on something sharp? I bet that your normal walk was altered, for at least a few steps.

Additionally, pain affects our accessory joint motion. This is the movement which is necessary for normal range of motion, but is not under voluntary control – for example: joint rolling and sliding. It allows us to move smoothly, and when it is lost, we lose that ability.

Osteopathy can inhibit nociception, thus allowing better freedom of movement. (5)

Impaired Fluid Dynamics

Deoxygenated blood and lymph (waste product fluid) moves passively, driven by muscular contraction and movement.

For reasons mentioned above, when we are in pain, we cannot move or contract/relax our muscles efficiently, which leads to fluid stasis. Coupled with blood vessel constriction resulting from an increased stress response (6), and we have a situation where there is poor clearance of metabolic and inflammatory waste products.

There are many osteopathic techniques designed to stimulate the lymphatic system and facilitate the circulatory system – enhancing the clearance of these waste products.

Specific Features of Low Back Pain

Mechanical Strain

Mechanical strain occurs when nerves in the low back are tensioned beyond their tolerance.

Mechanical low back pain is often described in terms of joints, ligaments and muscles, and whilst these tissues can be strained, it is the deformation of nerve tissue that is responsible for pain – muscles and joints don’t sense, nerves do!

Nerve tissue is highly sensitive, and it’s role is protective, so often we will experience pain without any major strain to other tissues, which is very typical of low back pain.

This type of pain is characterised by an aggravation, or relief with certain movements and positions. As a result, using manual techniques designed to facilitate movement and resolve the strain pattern, most mechanical low back pain responds well to osteopathic treatment.

Generally it is advised to continue moving as normally as possible during the recovery process.

Treatment of mechanical low back pain should also include a graded movement approach, to restore function, so that you can return to doing the activities that make up your life. You should also increase the loading of the tissues, to build resilience, so it doesn’t happen again.

Inflammatory Low Back Pain

Inflammation is a normal immune response, involved in the process tissue repair.

When we experience trauma to body tissues, there is a local inflammatory response. The trauma can be overt – fall, lifting, contact injury or repetitive – work related, sport related.

When inflammation affects the dorsal root ganglion, a collection of sensory nerve bodies near the spinal cord, then we experience pain.

Inflammatory low back pain is characterised by presence in a wide variety of positions. There is often an overlap between mechanical and inflammatory low back pain, the issue is finding the dominant factor and addressing that primarily.

The common recommendation for inflammatory low back pain is to use NSAIDs (anti-inflammatory medication). This can help in the short term, but there are side effects, which include the inhibition of certain factors required for the remodeling of the tissues. NSAID use should be determined on an individual basis by your healthcare practitioner, with a full discussion of the risks and benefits.

Rest, or more accurately, avoiding aggravating activities can help with short term relief.

Osteopathy can help with inflammatory low back pain in a few ways. Addressing the strain patterns that caused the initial tissue trauma and thus inflammation, enhancing immune response and affecting local circulation. (7)


So far we have outlined the general and specific features of low back pain and how osteopathy can help. However, the question still remains, does osteopathy work for low back pain?

To be perfectly honest, this is one of the hardest questions to answer.

Research Says Maybe

In research, individual studies are performed, and then studies that investigate similar things are reviewed to see if there is a consistent outcome.

There have been 3 notable reviews of osteopathic management of low back pain.

The results show low to moderate effects. (8,9,10) This is generally positive, but not unequivocal.

However, there isn’t any treatment for low back pain that is (unequivocal).

What does this mean to you?

Well really, low back pain is quite individual, studies and reviews take averages, thus discarding the individual differences in response to a certain effect.

For example, if you took a room full of 10 men and 10 women, the average number of ovaries per person is 1.

Research can be like this, a few people can respond really well, and a few really poorly, and thus the average effect is unremarkable, though for the people whom it worked really well, this is not reflective of their experience.

Is It Safe?

Whilst there are risks involved with osteopathy, there is a sparcity of evidence directly studying osteopathy, so we must draw on broader manual therapies, which show mild side effects (short term soreness) are pretty common (40-50% of people experience this) and serious adverse effects (disc herniation, cauda equina syndrome) range from 1:~38,000 to 1:3.7-100,000,000 respectively. (11)


Those who do not seek appropriate management for their low back pain initially tend to experience more frequent bouts, for longer.

Osteopathy is relatively low risk, and there is supporting evidence for the treatment of low back pain using manual therapy and exercise/rehabilitation.

Usually you should see improvement within the first 2-4 visits, however, osteopathy, like anything worthwhile, takes time.

One of the biggest issues I see is people who don’t complete a course of treatment.

Thus, they improve, but they do not completely resolve – some of the protective behaviours are still present.

In order to prevent this, the use of outcome measures (functional tasks, movement assessments and psychological screening) enable us to detect change beyond “it doesn’t hurt anymore”.

In most circumstances, a pain free period of at least 3 consecutive months, in addition to positive changes on outcome measures would be deemed a resolution.



This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




1) Incidence of adult LBP

2) Incidence of adolscent LBP

3) Prognosis of LBP

4) Osteopathy and ANS

5) Cutaneous regulation of motor control

6) Neuronal control of circulation

7) Neuronal control of skin function

8) Review of osteopathy and low back pain 1

9) Review of osteopathy and low back pain 2

10) Review of osteopathy and low back pain 3

11) Adverse events in manual therapy