In this text, I’m back to continue looking at some of the myths surrounding lower back pain.
This time I’m looking at one of the myths that is very ingrained into our day-to-day life, from how we sleep, how we walk, how we dress, how we eat, how we work, and even how we do the things that we find enjoyable. It’s always there, always watching and judging what we do with our bodies. I’m talking about the myth of posture.
Who has never, while growing up, been told by their mother that all their other health problems are caused because they spend so much time with their necks flexed on the phone or computer? Or told to sit upright by their teacher while at school?
I didn’t read your mind and I haven’t been stalking you for most of your life to know this. It just has been well demonstrated that throughout the world, the general public and health care professionals often hold the belief that some postures are harmful and should be avoided (Christe, Nzamba et al, 2021; Christe, Pizzolato et al, 2021; Korakakis et al, 2019), typically considering the safest way to sit is avoiding spinal flexion (Slater et al, 2019) as a slightly extended posture is also often considered the best position (Slater et al., 2019).
Despite these common beliefs, there is no strong evidence that avoiding what are deemed as incorrect postures prevents back pain (Slater et al., 2019). Which begs the question: why are we still calling them incorrect in the first place?
Let’s try breaking this down. How about we first start by looking if ‘improving’ the way we hold our body (assuming there is a better and worse way of doing this) leads to less pain.
Laird, Kent and Keatin (2012) performed a systematic review where they looked at studies examining the patterns of lumbar muscle activity, lumbo-pelvic kinematics (fancy way of saying how your pelvis moves), posture patterns and how these affected measures of pain and activity. The studies they found looked at different forms of exercising including the overhyped swiss ball and motor control exercises as well as measuring the electrical activity of your muscles or giving you real-time feedback of how your muscles are activating so you can change it (biodfeedback) (Laird, Kent and Keatin, 2012). Out of 12 studies, mostly of poor quality, only one found some improvement of pain, the others not showing any changes in pain or activity with the interventions, and on the one pain improved, there was no change in how the muscles were activating at the end of the study (Laird, Kent and Keatin, 2012).
So doing some fancy exercises with the aim of improving your posture doesn’t seem to either improve your posture or reduce pain. The whole story about your core being weak and underactive and that is why your posture is poor and you’re in pain doesn’t seem to hold up. Lima et al (2018) actually found that people with lower back pain had increased activity of back muscles across different day to day tasks such as picking up and object from the ground or standing up. This makes me think that actually focusing on having your muscles very active all the time could actually make this worse.
It has actually been shown the notion that people with low back pain must be careful and ‘protect’ their spine, thus bracing their muscles and moving in a more guarded way of moving is associated higher level of fear and lower self-efficacy (Slater et al., 2019) – ability to manage their own health.
So far we’ve been talking about postures we can actively control. What about when we have deviations from the considered “ideal” posture that we can’t change, such as in the cases in which people have differences in the length of their legs and this to our spine not being completely straight. Sheha at all (2018) examined this in a literature review and reached the conclusion that the currently available evidence is often contradicting, with generally small, underpowered studies and few randomized trials, leaving us without a clear correlation between a difference in leg length and development of back pain.
Possibly because of this poor correlation between posture and back pain, interventions focused on body alignment and posture such as back supports, shoe insoles and ergonomic programmes have shown to be ineffective on both preventing and treating lower back pain and are not recommended in guidelines (Foster et al, 2018)
So far we’ve seen that there is no match between how our muscles activate and our body moves or sits and having back pain; that even when attempts are made to change our posture, this doesn’t actually change our posture or improves pain; and even if out body doesn’t fit into this abstract ideal of symmetrical perfection, it doesn’t mean we will be developing back pain.As we have explored, the available research doesn’t allow us to establish a causal relationship between having a certain type of posture and developing back pain. We see that people can present with flexed postures, however we can’t say that isn’t a consequence of pain instead of the other way around.
Yet, non-evidence-based beliefs about our posture being harmful still prevail and are reinforced by fear inducing messages in different forms of media around us (Slater et al., 2019). As I mentioned in a previous post, research suggests that these negative beliefs about back pain are what actually can make you experience worse pain, be more disabled by it and be less likely to recover (Burgess et al, 2020; Lee et al, 2015; Morton et al, 2019). A more useful message for your health is to not stay in the same posture for long, be it flexed or upright, and be active more often (Foster et al, 2018; NICE, 2020). You can add that to the list of benefits of exercising.
As a healthcare professional I feel responsible and thus I’m trying to debunk some of these myths and I hope I’ve managed to argue why you should to. If you think I argued my point well, a good place to start is by sharing this post with the people you know.
If any part of this text didn’t make sense and you have questions, or you know about a piece of evidence that contradicts my argument please leave it in the comments. Dialogue is important to continue learning.
I’ll see you the next one. Until then – keep learning.
References:
Burgess, R., Mansell, G., Bishop, A., Lewis, M. and Hill, J. (2020). Predictors of functional outcome in musculoskeletal healthcare: An umbrella review, European Journal of Pain (United Kingdom), 24(1), pp. 51–70. doi: 10.1002/ejp.1483.
Christe, G., Nzamba, J., Desarzens, L., Leuba, A., Darlow, B. and Pichonnaz, C. 2021. Physiotherapists’ attitudes and beliefs about low back pain influence their clinical decisions and advice, Musculoskeletal Science and Practice. Elsevier Ltd, 53(April), p. 102382. doi: 10.1016/j.msksp.2021.102382.
Christe, G., Pizzolato, V., Meyer, M., Nzamba, J. and Pichonnaz, C. 2021. Unhelpful beliefs and attitudes about low back pain in the general population: A cross-sectional survey. Musculoskeletal Science and Practice. Elsevier Ltd, 52(August 2020), p. 102342. doi: 10.1016/j.msksp.2021.102342.
Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. In The Lancet (Vol. 391, Issue 10137, pp. 2368–2383). Lancet Publishing Group. https://doi.org/10.1016/S0140-6736(18)30489-6
Korakakis, V., O’Sullivan, K., O’Sullivan, P. B., Evagelinou, V., Sotiralis, Y., Sideris, A., Sakellariou, K., Karanasios, S., & Giakas, G. (2019). Physiotherapist perceptions of optimal sitting and standing posture. Musculoskeletal Science and Practice, 39, 24–31. https://doi.org/10.1016/j.msksp.2018.11.004
Laird, R. A., Kent, P., & Keating, J. L. (2012). Modifying patterns of movement in people with low back pain -does it help? A systematic review. In BMC Musculoskeletal Disorders (Vol. 13). BioMed Central Ltd. https://doi.org/10.1186/1471-2474-13-169
Lee, H., Hübscher, M., Moseley, G. L., Kamper, S. J., Traeger, A. C., Mansell, G. and McAuley, J. H. (2015). How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain’, Pain, 156, pp. 988–997. doi: 10.1097/j.pain.0000000000000146.
Lima, M., Ferreira, A. S., Reis, F. J. J., Paes, V., & Meziat-Filho, N. (2018). Chronic low back pain and back muscle activity during functional tasks. Gait and Posture, 61, 250–256. https://doi.org/10.1016/j.gaitpost.2018.01.021
Morton, L., de Bruin, M., Krajewska, M., Whibley, D. and Macfarlane, G. J. (2019). Beliefs about back pain and pain management behaviours, and their associations in the general population: A systematic review, European Journal of Pain (United Kingdom), 23(1), pp. 15–30. doi: 10.1002/ejp.1285.
National Institute for Health and Care Excellence (NICE). 2020. Low back pain and sciatica in over 16s: assessment and management NICE Guideline [NG59], December 2020. [Online]. Available at: < https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sciatica-in-over-16s-assessment-and-management-pdf-1837521693637 >
Sheha, E. D., Steinhaus, M. E., Kim, H. J., Cunningham, M. E., Fragomen, A. T., & Rozbruch, S. R. (2018). Leg-Length Discrepancy, Functional Scoliosis, and Low Back Pain. In JBJS reviews (Vol. 6, Issue 8, p. e6). NLM (Medline). https://doi.org/10.2106/JBJS.RVW.17.00148
Slater, D., Korakakis, V., O’Sullivan, P., Nolan, D., & O’Sullivan, K. (2019). “Sit up straight”: Time to Re-evaluate. In Journal of Orthopaedic and Sports Physical Therapy (Vol. 49, Issue 8, pp. 562–564). Movement Science Media. https://doi.org/10.2519/jospt.2019.0610
The Physiolosopher 