• Dr. Eric I. Degis, MS, DC

The Genesis of Low Back Pain!



To understand the causes of low back pain, we need to go back in time. Far, far, back. As in, then there was light, a big bang and…. well not that far back, but at least back to the 1950’s.

The 1950’s are when low back pain started?


Not started, but it was a turning point in the history of low back pain in the USA. A study done in the 1950’s looked at employees who worked in power plants. The study showed, that at the time, the workers in the control rooms needed to get up every 30 minutes and walk across the floor of the plant to reset the switches which controlled the pressure release valves. Their job demanded they be exact, every 30 minutes, no longer. In the following years, those same workers were given a new luxury, a remote switch that was located at their station. They no longer needed to walk across the plant and back every 30 minutes. They could now sit for the duration of their shift of 8 straight hours. What a wonderful perk!

What relevance did this study have and what did it show us?

One finding that came of this study (it wasn’t the actual focus of the study) was that those workers who had to trek across the plant, back and forth 16 times a shift, demonstrated very few instances of low back pain and very few missed time at work as a result of low back pain. By contrast, those employees who sat on their rumps for 8 hours and moved very little, had a dramatic increase in low back pain, almost 50% more, and proportionally lost more workdays due to the low back pain. These findings seemed insignificant at the time because the study had other objectives in mind, but…... fast forward 70 years and what are we seeing now? A significant increase across the board of low back issues, to the toll of 80% of the US population who will experience low back pain, which will equate to approximately 190,000,000 lost days of work annually, at a cost to our healthcare system of roughly $86 Billion annually (this does not include lost wages!).

For those of you who thought we had a handle on it with our focus on core stability, fancy Aeron chairs, Pilates, advanced surgical procedures, etc., those numbers have only continued to rise by 54% since 1990!



Houston, we have a problem!



So, are we doomed? No, it may seem hopeless, but it is not.


Do we stand a chance? Yes, but it depends on many factors.


Is there an answer to all of this? It is complicated, but yes there is an answer.



Understanding how low back issues develop (long before the pain starts) is paramount to us stopping the progression. Unlike most of those so-called experts who primarily focus on your low back after the pain starts, we need to look at it before the pain begins.

Without getting into too great a discussion (i.e., I don’t want to bore you!) There are certain forces that are exerted on the inner structures of the low back (disk), that over time will create slow degradation and weaken those structures from the inside-out. Often though, this process goes completely undetected because there are no nerve endings (no nerve endings no perception of pain).

I analogize it to taking an ice pick and whittling away at the inside of the disk all without us knowing it is happening. When we round the curve in the lower back and bend (flex) forward this type of internal stress is put on the disk without us knowing it. Normally the curve in your low back is curved inward (concavity/neutral) but when we bend forward at the waist, we lose that neutral curve and flexion takes place. Flexion from the top (bending forward) is often the mechanism for pain in many low back injuries. Bending over to pick up your child. Bending over to pick up a box. Bending over and picking up a pencil (weight does not matter, it’s the bending forward/flexion!)

Then there is Flexion from the bottom up. This is less obvious and most of us don’t even know it exists or is occurring. Some call it tucking tail or a posterior pelvic tilt. It involves flattening of the curve from the bottom up.

Both are destructive and both are painless while the damage is occurring.

I can reference dozens of movements and activities that you are performing each day that induce flexion in your spine which in essence is eating away at your internal structures like an ice pick.


What we saw in the 1950’s study was a small sampling of how sitting can increase the incidence of low back issues. At no point in time are we sitting more as a society than today. And at no point in time have we had this high of an incidence of low back issues. It is not a co-incidence.


We sit at work (which may be home these days). We sit to watch tv often in contorted positions. We sit on our Citi bikes and Soul Cycles and Pelotons. We sit to eat and study and read and …. well, we sit a lot it seems.


So then, why is sitting so bad for our low backs?


Remember the flexion thing I mentioned?

Sitting is bottom-up flexion.

What?

I don’t see it.

Like I said you don’t need to see but if your disk were herniated and irritated, it would tell you by initiating a pain. But since it isn’t normally painful, we don’t acknowledge it as a damaging stress.

That’s the issue. If we don’t perceive something as painful then we assume it is fine.

Sitting causes a degree of tucking tail/posterior pelvic tilt, which over long periods of time contributes to micro-damage (it pushes the disk backwards and degrades it).

After the pain of a low back issue subsides most people go back to sitting, which is adding further degradation. A vicious cycle that only gets worse over time.

How does this all get resolved?



My objective is to educate and make people aware. In order for low back issues to be better managed, we need to reduce or eliminate those physical stressors that when put on the low back, increase breakdown. We can start with sitting less!


Simple enough, right? I wish it were, but here are some tips and guidelines that will help you break the cycle.


1) Do not think about eliminating sitting (you can’t eliminate it), but rather reducing it. Especially, be aware of the amount of time you sit in a row.

a. A general rule is to sit no more than 20 minutes at a time.

i. At or around 20 minutes, we see changes physically and physiologically in the disk. Prolonged sitting destabilizes the low back structures.

ii. Sitting for 60 minutes in a row is much worse than sitting for 20 minutes times 3 with micro breaks in between.

b. Set a timer, get up and walk around for a minimum of 30-60 seconds every 20 minutes. It will then reset your internal damage timer.

c. Add in a 1-2 minute continuous walk every 3rd time you get up.

d. After a day of sitting (with standing breaks), go for a 30-minute walk.

e. Stretching your hips and lower extremity can help (guidelines in a future blog post).

f. Riding a bike is not going to help, it’s sitting!

2) Buying a comfortable/ergonomic chair is not the answer (sorry, Herman Miller).

a. Anything that encourages you to sit longer is only hurting, not helping.

b. I suggest sitting on a hard surface so that lack of comfort forces you to move more ( I am not kidding)

3) Sitting on a Large physio ball (exercise ball) is not the answer.

a. It is sitting!

b. Studies have shown the unstable surface (ball) and sitting compounded the internal stress on the low back.

4) Stand and eat at a counter when possible.

5) Stand on the subway or train.

6) Walk to work instead of taking mass transportation or even that Citi bike.

7) Take standing breaks during long movies (they are all at home now, so that’s simple).

8) Use your Peloton for shorter periods of time (30 m classes) and not every day, especially if you sit all day for work. Get out of the saddle when possible.

9) Standing desks, which are useful, can be combined with sitting. Some standing desks have automatic settings to raise or lower them at a desired time. Make that time 20 minutes. Sit for 20m, stand for 20m. Standing, without moving for long periods, is also discouraged. Maintain those short walks every 20 minutes during long standing periods as well.

10) A variable sitting position is better than a static position.

a. There is no perfect posture while sitting. Sitting “upright” is not going to protect you if done too long. Sit “upright”, sit with your leg crossed, switch the leg, lean all the way back, etc. Just mix it up, and then get up in 20 minutes.

11) Do not think that sitting all day needs to be followed with strenuous resistance training to “balance it out”. The sitting will destabilize your low back and the resistance training will increase risk of injury. It is a bad combination.

a. If you are going to do a strenuous class or lift weights, you better be getting up every 20 minutes during the day, and you better precede the resistance training with 20-30 minutes of continuous walking to reset the internal disk structures.

b. The sitting stress you create cannot be offset with something else. You need to lessen the sitting stress (i.e. sit less).

c. Do not sit and lift weights. It’s sitting. And it is now coupled with external resistance. Stand and exercise. If you don’t know how, or need advice, just reach out and I’ll guide you. There are very few exercises that can’t be modified, but if it can’t it should be eliminated.

d. I know this may not “sit well” with some, but Yoga, Pilates, and Barre are not going to offset the effects of sitting either. Matter of fact, certain postures and movements may increase the chance of injury if you have been sitting all day.




Lesson of the day,

Sit less. Stand alternatively. Move more.


Movement is life!


Bowel movements, internal fluid movements, air exchange movement, intervertebral disk fluid movement/imbibition, etc.


Movement is Life!


Share this post with anyone you know who sits (that's pretty much everyone you know).


Until next time, be safe, be healthy, and be mindful of the world around you.


drd


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