The truth about sports, nutrition and pain!

Posts tagged ‘Poor posture’

Lower back pain

I don´t want to sound negative or anything, but most of you who will read this blog will, or already have had, an episode of lower back pain. To be exact and according to different studies, low back pain affects 80% of the population at one time or another in their life. Just so that you get a sense of how big lower back pain is I will mention some statistics:

  1. It is the 2nd most common reason for seeing a physician/doctor.
  2. It is the 2nd most common reason for disability, 100 million lost work days a year (1)!!
  3. It is also tremendously expensive, 100 billion dollars are spent each year treating this problem (2-3)!

So seeing its importance, I think we should talk about it a bit and try to dismantle some myths about it. First, I want people to understand that lower back pain can usually be classified into 3 different groups:

  • First red flags: These are caused by serious disease such as a tumor, infection or a fracture. Less than 2% of the people who have lower back pain, have it because of ¨red flags¨(4-6).
  • Second-Nerve compression: This affects less than 10% of the people who get back pain. An example of this could be sciatica.
  • Third Non specific mechanical factors: This basically means we have no IDEA why your back hurts and around 85-90% of the cases fall into this third class (4-6).

So, if you take into account what I just told you, less than 15% of the patients who have lower back pain (LBP) can be given a precise pathoanatomical diagnosis!! The other 85% are sometimes labeled with general terms such as sprain/strain or ¨non-specific¨, in other words they don´t know why your back hurts. The ¨good¨ thing about lower back pain is that it usually has a favorable natural history, meaning that only 5% of the patients with lower back pain will go on to have chronic lower back pain while the rest will (more or less) recover.

Ok, now that we know a bit about what lower back pain is and how it is classified, let´s start talking about some of the myths that exist out there on LBP.

  1. First myth and probably one that you have all heard at one point or another. Strengthen muscles in torso (back) or abdomen to prevent LBP. Until today there has been NO study that has demonstrated this. What has been demonstrated is that ENDURANCE and not strength is a key factor in preventing LBP (7).
  2. Second myth: performing sit-ups or crunches will increase back health. I already talked about this in my blog (here is a link to where you can read it, but just to summarize: no one should be performing sit-ups (8).
  3. Third myth: Tight hamstrings lead to back trouble. This is false, there is no study that demonstrates this. What can lead to back trouble is asymmetry, meaning if you have more flexibility in one leg compared to another (7-10). Also, some studies have shown that the more flexibility one has in the back, the greater the risk of having future back troubles, at least in ¨normal people¨. This doesn´t mean that people should not stretch, mobility is important and so is flexibility but too much can maybe lead to back trouble.
  4. Fourth myth: If you sit straight or on a Pilates ball you will prevent back troubles. First I want people to understand that there is no such thing as an IDEAL sitting posture. Tissue loads must be migrated from tissue to tissue to decrease the risk of any single tissue´s accumulating microtrauma. This is accomplished by changing posture. Even the ideal posture, where they tell you to adjust the chair so that the hips and knees are bent 90 degrees and the torso is upright, is only ideal for about 10 minutes. After 10 minutes tissues deform and the best thing to do is change posture again. So let me repeat this again, THERE IS NO SUCH THING AS AN IDEAL SITTING POSTURE, the best thing is to change posture every 10 minutes (11).
  5. Fifth myth: To avoid back injury when lifting, bend the knees not the back. This is partly right but also partly wrong, because to bend your knees or your back depends on a lot of things. Like the dimensions and properties of the load, the characteristics of the lifter, the number of times the lift is to be repeated, and so forth, and there may in fact be safer techniques altogether. Let´s use an example of a golfer, imagine every time he has to pick up a golf ball he has to squat, meaning bend his knees. Ok, maybe his back wouldn´t get hurt but his knees are sure going to hurt after 18 holes of play. So, to keep a straight back would be ideal but in most cases this is not REALISTIC. What you should always avoid when picking things up is a fully flexed spine.

I could go on with more myths but I think those are the most important. So it´s time to move and start talking about factors that we can do to prevent low back pain, but before this I will first talk about herniation. What exactly is a herniation? Is it really that bad, and how do we avoid herniation. This and more in my next blog. Until then.


  1. Biering-Soerense F. A prospective study of low back pain in a general population. Occurence, recurrence, and etiology. Scand S Rehabilitation Med 1983;19:71.
  2. Cats-Banil WL, Frymoyer JW. Demographic factors associated with the prevalence of disability in the general population. Analysis of the NHANER I data base. Spine 1991;16:671-71.
  3. Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers compensation on low back pain claims. J Occup Environ Med 1998:40:261-66.
  4. Agency for HEalth Care Policy and Research (AHCPR). Acute low back problems in adults. Clinical Practice Guideline Number 19. Washington DC, US. Government Printing. 1994.
  5. Danish Health Technology Assessment (DIMTA). Manniche C, et al. Low back pain. Frequency Managemente and Prevention from an HAD. Perspective. 1991.
  6. Royal College of General Practioners (ACGP). Clinical Guideline for the management of Acute Low Back Pain. London Royal College of General Practicioner.1999.
  7. Biering-Sorense F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine, 1984: 9:106-19.
  8. Battie MC, Bigos SJ, Fisher LD, Spengler DM, Hansson TH, Nachemson AL, Wortley MD. The role of spinal flexibility in back pain complaints within industry: A prospective study. Spine 1.
  9. Axler CT, Mcgill SM. Choosing the best abdominal exercises based on knowledge of tissue loads. Medicine and Science in Sports and Exercise. 1997: 29:804-11.
  10. Hellsing AL. Tightness of hamstring and psoas major muscles. Upsala Journal of Medical Science 1988. 93:267-76.
  11. Callaghan J, McGill S. Low back joint loading and kinematic during standing and unsopported sitting. Ergonomic 2001 :44(3):280-94.

Pain part 2 – Does bad posture cause pain?

The other day we saw that pain is very complex and that in most cases it´s produced in the brain. So, if it´s really produced in the brain, does posture or movement really matter? We have all gone to the physical therapist or doctor and have heard that ¨your back pain comes because you have too much of a curve in your back¨, or ¨your back pain or shoulder pain comes because of your forward head posture¨ or ¨your knee pain comes because you have too much of a pronation on your foot¨. Hell, I´ve done it, I´ve been saying that to my patients for years because that is what was taught to me.

Up to last year I had a client, XG, who always came to me because he had back pain. I would always tell him that his back pain was coming because of his posture. He had a forward head (still does) and a big lordosis (inward curve) in the lower back .I tried to correct his posture, I gave him exercises to do at home, I stretched him, I did everything you could imagine but his posture hasn´t really changed but guess what, his pain has, it´s gone!!

So what I´m basically trying to say is that there is no consensus on supporting a biomechanical (and posture) model of pain (1-10). Because:

• Postural and structural asymmetries cannot predict back pain and are unlikely to be its cause (1).

• Local and global changes in spinal biomechanics are not demonstrably the cause of back pain (1).

• A postural structural biomechanical model is not suitable for understanding the causes of back pain (1).

This is so because postural structural asymmetries and imperfections are normal!! The body has surplus capacity to tolerate such variation without loss of normal function. That is why there is little scientific evidence to show that posture will cause pain (2-5). If posture was a factor of pain how come you see thousands of people around with bad posture with no pain and thousands more with ideal posture in a lot of pain? That just shows that there is much more to pain than just posture.

This is not meant to deny that there is a correlation between pain and certain postures, but that this association is neither sufficient nor conclusive to justify our efforts to dictate people’s posture and movement. But what we do know for sure is that there is no ‘ideal’ posture, and any posture if maintained for too long will result in dysfunction, and maybe pain. The key is movement.

To end this article and the topic of posture and pain, and to confuse people even more, I will say that there actually is potential harm in  “addressing” the unsubstantiated claims of bad posture. Things just as: focus on “bad” movement or “bad” positioning have the potential to sensitize the individual into believing that a benign (wrong) positioning is in fact something that represents a threat. And as we saw yesterday in the video, pain is the response to threat, either real or perceived, and how we view our environment and ourselves within that environment can positively or negatively affect that threat response. So by addressing things that don’t have evidence to support them (bad posture), we are actually increasing the chance that an individual might have the very real experience of pain. We are creating a self-fulfilling prophecy. That is real harm – and it is evidenced (2-5).

I will finish by quoting some of Lorimer’s famous quotes and with a link to a video that demonstrates the tricks the mind can play on us.

Favorite Lorimer Quotes

  • “Pain is very complex.”
  • “We can’t treat every pain patient with a simple solution.”
  • “The best way to get rid of chronic pain is to chop the person’s head off.”
  • “As soon as you interact with the patient, you are in their brain.”
  • “Always do more today than you did yesterday.”

P.S In my last post I said that you can have an injury without having pain. Some of you didn´t believe me, which is normal, so references 7-12 demonstrate just that.

Also, those that have been following me may be asking themselves why I still  haven´t talked about how to deal with pain. The simple answer is that I first wanted you guys to really understand what pain is and change the way you think about it. With these 2 posts maybe you haven´t really understood it yet, but I probably made you look at pain from a different perspective. Now that we have this different perspective, in my next post I will finally talk about how to ¨deal¨ with it. Hope you liked the article, until next time.


1. Lederman E. The fall of the postural-structural-biomechanical model in

manual and physical therapies: exemplified by lower back pain. J Bodyw Mov

Ther. 2011 Apr;15(2):131-8. doi: 10.1016/j.jbmt.2011.01.011

2. Loeser JD, Melzack R. Pain: an overview. Lancet. 1999 May

3.Moseley, G. Lorimer. Reconceptualising pain according to modern pain
science. Physical Therapy Reviews 2007; 12: 169–178.

4.G Lorimer Moseley. Teaching people about pain: why do we keep
beating around the bush? Pain Manage. (2012) 2(1), 1–3.

5.Melzack R., Katz J. (2013), Pain. WIREs Cogn Sci, 4: 1–15.

6. Moseley GL. Pain, brain imaging and physiotherapy–opportunity is
knocking. Man Ther. 2008 Dec;13(6):475-7.
7.Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people
without back pain. N Engl J Med.1994 Jul 14;331(2):69-73.

8. Sher JS et al. Abnormal findings on magnetic resonance images of
asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5.

9.Melzack R, Wall PD, Ty TC. Acute pain in an emergency clinic: latency of onset
and descriptor patterns related to different injuries. Pain. 1982

10. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magneticresonance
scans of the lumbar spine in asymptomatic subjects. A prospective
investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.

11. Kleinstück F, Dvorak J, Mannion AF. Are “structural abnormalities” on
magnetic resonance imaging a contraindication to the successful conservative
treatment of chronic nonspecific low back pain? Spine (Phila Pa 1976). 2006
Sep 1;31(19):2250-7.

12. Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S,
Einhorn TA, Felson DT. The clinical importance of meniscal tears
demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J
Bone Joint Surg Am. 2003 Jan;85-A(1):4-9.

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