Do our patient's need fixing? Or do they need a bigger cup?

Do our patient's need fixing?  Or do they need a bigger cup?

Audience: Therapists and people in pain

Blog Style: Lots of questions to consider

To help me understand pain and injuries and to hopefully help people I need to simplify things. One of the simplest ways to view pain is with the cup metaphor. It certainly has flaws but it does help look at the "big picture" of treatment. The cup metaphor suggests that pain occurs when all of the stressors/loads in our lives exceed the space in our cup. When we overflow we have pain

Reconciling spinal flexion and pain: we are all doomed to failure but perhaps it doesn't matter

How is that for a title?

A major concern of strength coaches, physiotherapists and other health care professionals is teaching people to NOT bend their spines when they lift things.  It is assumed that spinal flexion is an independent risk factor for low back injury and pain.  For a detailed review please read here

The point of this short post is to consider the ramifications of the cadaveric animal models that investigate spinal loading and injury mechanisms and how this might inform clinical practice.

Background

One of the strongest arguments against spinal flexion are the numerous in-vitro (meaning dead animals) studies that look at what happens when you repeatedly bend and load a disc/motion segment.  Numerous studies (here, here, here and here) have shown that loading a spinal motion segment when it is out of neutral appears to be more injurious to the disc than if you just loaded the disc in neutral.

So, if you are biomechanist it would seem that its a slam dunk on one thing to recommend to prevent low back pain.  Try to keep your spine in neutral when you go to load it.  But, there are some issues. 

1. The advice doesn't seem to work.  We have been giving that advice for years and low back pain is still quite common.  See an older review here on a biomechanical analysis of stoop v. squat lifting
2. Many would say that those are DEAD spines.  They can't adapt like humans would to load.  That if we took a dead tendon out of a cow and pulled on it repeatedly that the tendon would fail - and no one would then argue that we should avoid loading tendons. (we don't by the way, we load tendons appropriately to have them adapt).

We now have a professional REACTION based on these arguments. Those who are challenging the conventional wisdom of avoiding spine flexion and are arguing that it is irrelevant for injury/pain.  Many would say we should ignore the in-vitro work because it is flawed.  I would not go that far and wanted to put forward another way to view this research

MORE BACKGROUND - Two Observations from the vast literature

Observation #1: In-vitro animal models don't load repeatedly to End ROM

In the animal model studies they bend the spine varying degrees.  Some work suggests that the amount of spine flexion is just to the end of the neutral zone which may be about 35% of max end ROM (Gooyers et al 2015 and Callaghan & McGill 2001) and other studies suggest it is more (not explicitly stated but it looks to be about 60-70% of max end range Wade et al IIRC)

Observation #2: Spinal Flexion is Unavoidable during lifting, bending and squatting

We typically measure spinal flexion as the difference in flexion of the sacrum versus the amount of flexion at L1 by devices that are strapped to the skin above those joints.  Numerous studies have shown that even when people try to maintain a neutral or lordotic spine they still have large degrees of flexion (typically greater than 20 degrees which is often more than 40% of max flexion).  Here are some examples below:

1. Kettlebell swings showing an average of 26 degrees of flexion 

2. Good morning exercises showing between 25-27 degrees of flexion

3. Squats and deadlifts showing 50% and 80% max flexion respectively (soon to be published MSc out of University of Saskatchewan with Scotty Butcher)

4. "Lordotic lifting" postures showing around 30 degrees of flexion when the trunk is only tilted 65 degrees forward.  Even when people tried not too flex they still flexed.  (See slide below)

you will flex no matter what.001.jpeg


5. Laura Holder (2013) showed the exact thing as Arjmand 2005.  Take a look at the picture and note how it looks neutral but it is flexed still.
 

still flexing when not deep.001.jpeg

So what is my point?

Alright.  Here we go.  The in-vitro studies do not stipulate that it is only end range flexion that is injurious.  Many just go to the end of the neutral zone (which seems to be different across studies).  The amount of flexion used to create a disc injury at times seems to be as little as 30% of max ROM.  (note: it is a hard to give a definitive answer for this because what is reported is the absolute amount of spinal flexion for a motion segment rather than how much it can move maximally). In the lumbar spine this seems to be around 15-18 degrees for the entire spine motion.

What is so interesting to me is that it seems like it is IMPOSSIBLE to avoid this amount of lumbar flexion.  Meaning people will regularly squat only to parallel and have 50% of max flexion or do a beautiful Kettlebell swing with around 50% of max flexion too.  Deadlifting or lifting from the floor is even more (80% of Max Rom according to Scotty's work).  Just look at the above picture - she looks in neutral with no flexion and we have 22 degrees!

My point (finally) is that both sides of this debate could be correct.  
 

Meaning, the in-vitro spine models COULD be valid.  Spinal flexion could be risk factor for disc damage. But, there might be little point in being concerned about it because it is impossible to avoid and hold on...disc degeneration is an absolutely normal and unavoidable part of being a human and is poorly related to pain! Meaning we get worried about disc degeneration contributing to pain but it might be just a tiny drop in the pain cup (not irrelevant but just kindling for a fire. ). Thus, don't worry about that little drop in the cup but worry about all the other factors that might be more important.

Potential and Practical Take Home Points and Opinions (one way to look at this)

1. Symptom Modification: If spine flexion hurts then you can certainly change it a little bit.  So, let symptoms be your guide in how you move sometimes.  Temporary avoidance might be the right answer for some people some of the time (I'd also say its wrong for some people and they need to expose to flexion but that is another blog)

2. Use other factors/goals to when making biomechanical decisions.  Meaning tweak your biomechanics for performance, to shift stress or to target different muscle groups or movements depending on your goals.

3. Follow good training principles when it comes to training and loading your spine - Don't do too much, too soon, dumbass.

4. Maybe don't freak out so much about spine flexion.  Recognize that it is a normal part of movement and other variables are probably more important for pain

5. Maybe we just avoid or minimize heavily loaded, full range lumbar spine flexion.  Not because there is specific research on the spine but because we do this with other joints as well.  

6. Again, similar to all joints maybe we should vary our spine postures during a number of tasks.  Meaning, if load management is important perhaps being able to lift, bend, squat, sit, row and flip with a variety of positions is the best way to balance the application of stress with the required time to rest and recover.  So maybe movement quality just means you can move anyway you like. And perhaps Preparation trumps Quality.

*I know these practical points are good because people on both spectrums of the debate will agree with some and disagree with others.  I've made no one completely happy.
 

 

Dear Mike and friends: why sitting posture is mostly irrelevant to future pain

I just read an interesting discussion about sitting posture and pain over at www.mikereinold.com.  Since I was mentioned I thought I would respond and I like those guys so I would enjoy talking to them about this topic.

Below I am going to quote what they wrote (its super long) and then respond to it.  I have tried to add references where appropriate.

Point Counter-Point from this discussion here

Mike's group will be in italics.  If I've bolded something it means its worth following up on.

MIKE AND CO:I can start. I’ll let you guys follow up, but I know when I sit at my computer for a long time with bad posture, I don’t feel better. So I feel pretty bad actually after sitting for like four or five hours working on the computer with bad posture. I just don’t feel,

– You feel worse.

– I feel worse. So I don’t know if that means anything.

– So let’s roll off that. What do you guys think? Why does Mike feel worse after sitting at his computer all day? That’s an interesting question. So his poor posture did increase his symptoms, but why?

I think honestly it depends. I think sitting for a prolonged period of time and not moving probably has a lot of things going on physiologically than just make you feel poor. I know that if I sit and I work in front of a computer for a long period of time, as opposed to standing and engaging with people, I feel better standing and engaging, being more social, moving my body. I bet physiologically there’s a lot of good stuff that goes on with movement. I think the big question is whether or not having a prolonged posture is gonna lead to pain. But I think the thing that we can probably all agree on is that when someone has a pain problem, certain postures will definitely exacerbate that.”

 

RESPONSE: You guys have all the answers here but you keep blaming the wrong culprit.

 Is it some “bad posture” that is the problem or is it simple that you aren’t moving? 

If Mike knows that its his “bad posture” that is the problem then why isn’t he sitting up straight with "good posture" to relieve the pain? Why doesn’t his body naturally figure out that he should sit differently?  This is the whole point of nociception.  It catalyzes movement.  We know this because I know Mike didn’t develop some wicked ass-ulcer from sitting.  He moved.  So nothing in this exchange really points to posture being the problem.  It points to the issue of just being sedentary, sitting and not doing anything.  So why is posture still blamed?

 

MIKE AND CO: “An interesting quote that came up, so Greg Lemond actually had a great quote. I think it’s safe to say Greg doesn’t listen to this podcast so we’re probably safe to chat here, but maybe he will if he reads this title, so what’s up Greg?”

My response: What’s up guys.  Lemond or Lehman.  No difference. Close enough.

"MIKE AND CO: But Greg put a pretty cool comment. He just said, you know, “loading is life” or something like that. I actually replied. I was like, “yeah, that’s pretty good.” Loading is life, ’cause somebody said it like, “poor posture increases load. It increases load on the tissue.” And he’s like, “well, tissue needs to be loaded.” And I thought that was actually a smart comment, Greg, sorry. But I also thought it was quite short sighted too because that’s him just implying all load is good."

 We have an inconsistent view of "load" in our profession

We have an inconsistent view of "load" in our profession

RESPONSE: I just meant loading is inescapable.  And for the most part loading is what makes us adapt.  Too much, too soon and what we aren’t prepared for is probably more of an issue.  Hence why I would argue that Preparation trumps Quality.  Meaning your posture is less important than whether OR NOT you are prepared for those loads.

 

"MIKE AND CO: But what I added to the conversation was, well, can we say that certain postures, as well as other things, like a type III acromion or something like that, but can certain postures then decrease the capacity of the tissue to handle load before symptoms occur, or partial tearing, or inflammation occurs?"

 

MY DUBIOUS RESPONSE: I think this is a great point and we often discuss it in the spine or with running.  Posture can definitely change the loads.  But do we think that a postural change is the best way to really manage loads?  I’d argue that it is a small drop in the bucket.  But I don’t think its irrelevant.  If a runner has knee pain we might have them run with a higher cadence which decreases knee loads about 10%.  Sometimes this is enough to effect a change.  But is THAT the best way to manage the total load on someone?

"MIKE AND CO: So it’s real short sighted to say to just say you need a load. I mean, maybe it’s really like the issue of, are there things like posture, does that make your total capacity to load lower? And I added that to the question. I don’t think anyone’s chirped back at me yet, but I’m sure they will. I don’t know. So based on that, I don’t know, keep the discussion going"

 

MY LACLUSTER RESPONSE: I don’t know either.  To add to our lack of knowledge we can see this with spine flexion debate.  Many would say its safer to minimize spinal flexion because the load on the disc will be too much – they will argue that of course some spine flexion is fine but we could overdo it.  Conversely, the adaptation argument is that as long as we slowly load the spine in flexion and manage ALL the loads on the person that they will be able to adapt to those positions.  So the debate is really about adaptability.  If adaptability is finite then perhaps we want to minimize flexion sometimes if we are already managing all of the other loads.  I don’t really know here.

 

 

"MIKE AND CO: I think that’s just building upon what we’ve been saying, is you put yourself in a seated position, your lumbar spine is flexed relatively, so that means all the surrounding musculature is trying to hold on in a flexed position. And then you go up, and you’re upright now, you’re extended, and now you’ve gotta do things in that position. Can your tissue respond? In some people yes, in some people no. What’s the stress in their life? What’s going on in other things? I think there’s so many different factors. I think it’s one small piece.

– Yeah.

– I agree with that."

 

MY WINNING RESPONSE: Here is where I disagree with you bastards.  Sitting is not hard on the back nor is it hard on the muscles.  We sit in a flexed posture because it is easier.  Do you think it would be better for the person to sit upright all day?  That would be even more difficult. It is regularly suggested that sitting away from a neutral position somehow loads the spine and soft tissues in a manner that people can’t tolerate.  But with the few studies that look at either muscle activity or spine loads we see that there are only tiny differences in EMG activity between upright and slump positions.  Both show less than 15% of maximal activity and the differences being approximately 2-3% of max activity between all positions (Caneiro et al 2010). 

Further, sitting erect can have increased spinal loads when compared to leaning against a padded wedge with both of those positions being less than 25% of what might be found when lifting a 19.8kg case (Rohlmann et al 2001).  And when the loads on the spine or connective tissues are compared to loads during exercise or physical activity we would see that those loads are much lower.

 

bad posture kids.001.jpeg

As for “can the tissue respond” – I think you need to forget about sitting here.  Its kind of irrelevant.  We prepare the tissue to respond by good solid training.  Who cares about sitting - that is not sitting’s job TO PREPARE THE PERSON FOR SOME OTHER TASK.  Sitting doesn’t fatigue the tissue.  If anything the opposite of the argument should be made.  Sitting is too restful for the spine.  Its not enough stress to make YOU adapt and make it resilient.  But if we stay in your world of "sitting is hard on the spine" what is your alternative?    Sitting up straight all day?Is it easier for the back it you sit up straight all day in a "good" posture.  What is the posture that “spares’ the spine?  I doubt it.  We can't vilify the posture.

 

 

"MIKE AND CO: But I was finding quite a bit that was linking prolonged postures with neck pain and a little bit of lower back pain. So I think it’s kind of like stress, and Dave and I talk about allostatic load, and Lenny just alluded to this. It’s all the influences in your body that are potentially leading to this. Maybe my neck starts hurting because I’ve got a lot of stress going on in my life. I actually have terrible posture. I have terrible load capacity in my neck ’cause I don’t exercise all the time. All these things are going to come together to give you a problem, right?"

 

 

MY RESPONSE: These are some great points here.  But why not just blame the stress in your life? Why not just blame the lack of exercise? You keep using the words “terrible posture” without there actually being any support for that term.  Again, take a look at the intervention literature.  Telling people to sit up straight with “good posture” does not work.  Those with forward head posture are not more likely to have pain.

 

"MIKE AND CO: Alright, so let’s go off that and let’s combine it with Mike’s comment to an extent here. What if you sit all day, and then you never do anything but sit all day?

– That happens everywhere, you know?

– Are those people in pain? Does it cause pain? Or is the question is, do we sit all day and then go play basketball?

– Right.

Or do we sit all day and then go do an overhead press with a barbell?

– Right.

– Maybe the issue isn’t that posture creates disuse, which creates muscle imbalances, and tightness issues, and tone, and some muscles that are used to not being on because of compensation and stuff like that. So it’s just, posture creates this cascade of things. And then it’s that we sit for X hours a week. You drive to work, you sit at a desk all day. You drive home, you eat dinner, you watch Netflix, and that’s it. And then on the weekend you try to play ball with your kids and all of a sudden your shoulder hurts. And they say well, it’s because of your posture."

 

MY COMMENTS: SHITBALLS GUYS! I’m not sure how you got here.  There are a lot assumptions about “compensations’, “imbalances”, “tone” etc.  We don’t have any literature or even a good argument that “posture” causes these things or that these things are even issues.  But, that is needs unpacking in another place.  Back to posture.

I think you might be a little inconsistent here when it comes to loading on the spine.  Earlier you said how hard sitting flexed was on the back.  Now you say that sitting leads you to be deconditioned to play basketball.  Which is it?  Is it hard on the back or is the load too low to be a good stimulus to adapt. Wait, I'll answer.  Sitting is easy on the back.  

 

But the real issue here is why are you expecting sitting to be a stimulus to allow you to play ball with your kids.  Stop blaming sitting.  Stop blaming posture.  It’s the fact that the Mom or the Dad don't load their body enough to prepare themselves for the weekend.  No amount of sedentary behaviour with “Good Posture” is going to fix that.  Again, it ain’t the posture and its not the sitting.  It’s the lack of preparation. 

worried about sitting.001.jpeg

 

"MIKE AND CO: And I would say, too, I feel like our treatment style here, our philosophy here is, we turn on muscles. I don’t know what the heck that means. I don’t know what the neurophysiology or the neuromuscular components of what turning on muscle is. But I always use this example with patients. It’s probably good to share here just analogy-wise. When you sit in your chair all day, your core doesn’t need to do anything. The chair is keeping me from falling to the floor. If I were to stand up, I have to use my core to engage a little bit. But I’m just sitting here, my core’s completely turned off because the chair is helping me stabilize so I don’t collapse into a pile of bones"

 

MY RESPONSE: See, you guys are inconsistent. Sitting is easy on the spine.  You just said it.  Why are you blaming it?

 

"MIKE AND CO: The second I stand up, if I’ve been doing that all day, you rock back on your static stabilizer, your back stabilizer, because your core is still off. I don’t know what that means. But again, it still is just not active."

 

MY RESPONSE: Just standing up doesn’t require a lot of muscle activity for anyone.  If you put 32kg on your back it requires 1-4% of max activity to stabilize your spine.  Even standing is easy.

"MIKE AND CO: And then you just start exercising, you start doing some of the drills we do, some of the rhythmic stabilizations for the core, just like a generic strength and conditioning program. And all of a sudden they go throughout life, and they use their core more during their daily life. We see that in here. So I guess maybe the real summary of this isn’t that posture doesn’t cause pain, but all the associated deficits, or associated consequences of having poor posture all day, and not having movement mirrorability, not ever doing any strength training, not working on your mobility, not trying to reverse your posture throughout the day, the consequences of that are probably gonna be what limits it."

MY RESPONSE: WAIT. STOP. Back up.  You guys keep adding in “poor posture” where you don’t need it FOR YOUR ARGUMENT.  You haven’t made the case that the posture is the problem.  It is everything else that you are talking about which I think is bang on!

 

"MIKE AND CO: But again, your body adapts to the stress applied or not applied. We always talk about the stress that’s applied, and then we build more resilient tissue by applying load. But remember, your body also will go in the other direction if you never apply load. That’s fine if you never apply load. But if you just sit, and you want to be the best sitter in the world, then you should probably sit more."

 

MY BRILLIANT RESPONSE: There you go.  Sitting posture is not the issue.  Blame everything else but sitting posture.

"MIKE AND CO: That depends on how we’re defining applying the load. Just siting for eight hours in this awful postural position might be enough load to break down the tissue that hasn’t had load applied to it, so to speak."

MY RESPONSE: What? You guys did it again.  Come on! You just said sitting took no muscular effort.  Now its going to break down the spine because of some “awful” position.  Again, replace the “awful” position in your argument with an “upright” neutral position.  Do you think that will be better?  No way.

 

"MIKE AND CO: Is going down, it’s more sensitive to issues. But somebody else brought up another point too. I just thought it was interesting, but again, it’s the whole pain science comes from the fear mongering thing. You don’t want to make the patients afraid. I’m like, afraid? Is that the right word? I don’t think anybody’s quivering in bed, like scared of the dark that they can’t move. I think, look, we’re creating awareness and caution. Not fear. I don’t know who Nobody’s like that. Like telling people to work on their posture, like, how can that be a bad thing? I don’t think anybody is belaboring it that it’s evil to sit in bad posture. But there are so many good benefits of getting out of that position, of reversing your posture, having variability in your movements and stuff."

 

 

MY RESPONSE:  You wrote "I don’t know who describes it like, “oh don’t sit like that, it’s gonna break right now.”  - What?  You just did in this whole piece.  You keep talking about “terrible and awful” posture that “might be enough to break down the tissue”. 

 

Regardless, there are more relevant points why its wrong to blame posture and those points have little to do with "pain science". Really, its the biomechanics that often challenge the biomechanics:

 

1.     The research does not support posture as problem.  Sitting is not related to more low back pain

2.     There is nothing wrong with slouching.  It feels good.  It can actually be a symptom modifier.

3.     If we focus on posture we are focusing on the wrong things.  You guys have already said this but the alternative is not worry about posture but address all the things in someone’s life that could be sensitizing them.  (Not being active, not engaging in hobbies, no sound training principles and worrying about their goddamn posture J

4.     Sure, variability is fine.  And a part of variability is just telling people to sit however feels good.  This means all positions are welcome even the “awful and terrible” ones.

Here is my take on when posture matters:

1.  Performance
2. Symptom modification – if it hurts try something else

In summary, it seems that there is more concern about the things we aren’t doing when we sit rather than the actual posture associated with sitting.  Lets just focus on those things.

If you want to stretch your hamstrings please continue to do so.

If you want to stretch your hamstrings please continue to do so.

was informed of a recent post in The Huffington Post entitled "Stop stretching your hamstrings".  This style of article (where we lambast some exercise)  has been pretty popular for a number of years and I have certainly contributed my share.  This one in particular I could have written 20 years ago when I was pretty strongly against yoga and stretching. I'd go out of my way to find any research that supported my bias.