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.

Conclusions

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.

 



 

References

(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)

Exercise For Low Back Pain

Fit girl lift weights at fitness gym center. Deadlift workout.

Any article about exercise for pain needs to cover one important fact before it goes on:

The body will tend towards self-correction/health/resolution, if, and that’s a big if, the right conditions are present.

The biggest challenge facing an osteopath, or any other therapist, is finding, or more likely, stumbling upon, the right conditions for the individual seeking help.

Whilst there are general guidelines to abide by, every one of us has a unique set of experiences, thus different stories, explanations, treatment techniques and movements are required to facilitate a recovery; not to mention all the environmental factors that come into play.

This article intends to discuss the general principles that should underpin your actions when exercising for/with low back pain.

Where Most Back Pain Exercise Programs “Go Wrong”

Most back pain exercises or exercise programs are based on the notion that pain is the result of specific factors, and that these factors can be specifically identified and then specifically addressed.

There are a variety of factors that can contribute to low back pain, but aside from a history of previous episodes of low back pain, nothing drastically stands out as being identifiable. (1)

As an aside, this perhaps points the finger at us, therapists and rehab professionals, who are not doing a good enough job in the first place (on a population, not individual level).

It is also highly important for sufferers of low back pain to understand, as many people decide to cease treatment/rehab as soon as their pain is gone, rather than concluding the full course of treatment and restoring “lost” function.

Unfortunately, it is very difficult to specifically assess and as a result, address them with targeted exercises.

So knowing that specific factors may be hard to identify and treat, it seems more important to build resilience with a complete mobility, strength and conditioning program.

Take home point number 1: exercise programs for low back pain should not attempt to be specific, but rather improve all physical qualities.

There Are No ‘Good’ And ‘Bad’ Exercises

Another misconception surrounding exercise for low back pain is the concept of ‘good’ and ‘bad’ exercises.

Generally, if you are reading a fitness article, the concept of “neutral spine” is mentioned quite a lot. Lifting should always take place with a neutral spine, regardless.

If you are reading a rehab article, limits might be imposed on external loading, as in, any lifting above 10 kg is bad, and must be avoided.

Or you might read a medical article which mentions you should simply avoid things that hurt.

All of these comments have a place, and are neither right or wrong without any context to define them.

A ‘good’ exercise is one that you can do safely, is suitable for your current ability, is able to be gradually progressed and fits in with your needs and wants (aka your goals).

Take home point number 2: blanket statements and absolutes do more harm than good. There are times when a moderate approach doesn’t work and more extreme action needs to be taken, but it is rarely either or. Exercise selection is based on your needs and wants, not an arbitrary definition of good and bad.

Self-Limiting Movements

This is a concept that was popularised by American physical therapist Gray Cook, in his book Movement.

Self limiting movements/exercises are those that have an inbuilt “coaching mechanism”, meaning doing them forces you to increase your awareness with movement, and often times with these type of movements you can only perform them correctly, or not at all.

Utilising self limiting movements as part of an exercise program for low back pain allows you to safely challenge your body and brain, leading to improvements, without the risk of overdoing it.

There are many different examples of self-limiting exercises. The specifics are not as important as being able to move with increased awareness and a low risk. This is a big focus of our exercise programming for low back pain, especially in the early stages.

Take home point number 3: a good exercise program will provide both a challenge and the option to “fail safely” – thus reducing the fear associated with facing more demanding movement challenges.

Our Approach To Programming

There is no one way to program exercise for low back pain. As long as the programming is underpinned by sound principles, and not “technique based”, then it should be sufficient.

We strive for more than sufficient, we strive for optimal.

As such, over the years our approach to exercise programming for low back pain has been refined to what it currently is. Chances are, in another 5 years it will be further refined, but the vast majority will be consistent, as it is all principle based.

First, we consider the body as a whole. We don’t only do “low back” or “core” exercises, but rather we devise a total body program. This is the underpinning principle of osteopathy, and is also applicable to exercise programming.

Second, we ensure that of physical qualities are developed in the right sequence.

If we start with osteopathic manual treatment in the consultation room, we then progress to mobility and flexibility exercises.

These will usually start on the ground, as this provides the most stable environment, thus is the least threatening.

Considering pain occurs when there is a perception of threat by the brain (if you haven’t already, have a read of Pain Basics), this is one of the best ways to regain movement and avoid inefficient compensation patterns taking over.

From there you are looking to build “motor control” – this is simply the ability to control movement well.

We can call this stability, but that implies static positions and discounts the movement component. This is actually achieved simultaneously with improving movement/mobility/flexibility.

We can consider mobility as “end range strength”, and we are simply progressively challenging you so that both qualities improve.

Once you have achieved adequate movement and control (adequate is based on your individual needs), if you want and/or need, we would add load. This might be in the form of external resistance, increased leverage challenge or even changing the tempo.

Only when you are moving competently under load do we add a conditioning component – that is, more volume of work. This is the challenge of fatigue to your new found movement abilities, and if done correctly, is the difference between breaking down when the going gets tough and being able to withstand (almost) anything.

Take home point number 4: whole body, principle based programming that utilises appropriate methods of progression yield the best long term outcomes (based on clinical experience and research) (2) for sufferers of low back pain.

Conclusions

There is a well worn quote:

Methods are many, principles are few. Methods always change but principles never do.

This served as inspiration for this post – there is no point showing you how to do an exercise with no context as to whether it is appropriate for you or not.

Rather, it is important to have an understanding of why you are doing something – even if you only care about the “what”.

This understanding means you will not chop and change based on the latest article in your newsfeed.

It means you will take the time to get things right, knowing that making progress is all the matters, even if it is “slow”.

It also means that you have a better chance at a good outcome and are less likely to become a statistic of low back pain recurrence.

Reducing the article to four sentences, we would end up with something like this:

  1. Do something you enjoy doing, that has intrinsic reward – there are no “good” or “bad” exercises.
  2. Ensure you take a “whole body” approach to exercise. Don’t simply focus on “low back exercises”.
  3. Start slowly, progress gradually.
  4. Vary the stimulus over time, but not too much or too often (or you won’t elicit adaptations).

 

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.

 



 

References

(1) Incidence and risk factors for low back pain: http://www.ncbi.nlm.nih.gov/pubmed/24462537

(2) Resistance training and low back pain in active males: http://www.ncbi.nlm.nih.gov/pubmed/20093971

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)

Effectiveness

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)

Conclusions

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.

 



 

References

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