Why Lifting With A Straighter Spine Doesn’t Reduce Your Risk Of Back Pain

A 5-minute read…

There is a common and popular belief that you should keep your back straight, stiff, and neutral as Switzerland when you lift things to reduce your risk of back pain and injury, and this is one of the most divisive debates I regularly have with so many people. However, it’s just not true!

Now before you all rush off to the comments section to post some PubMed links of your favourite moustached spine-saving guru’s research… Let me make it as clear as I possibly can, that I’m not saying we don’t have to or should NEVER lift some things, sometimes, with stiff, straight spines.

All I am saying is don’t be fooled into thinking that lifting something with a stiffer, straighter, more neutral spine reduces your risk of back pain or spinal injury. Because it’s just not that simple!

Where’s Your Evidence?

But where’s your proof and evidence for this Adam… I can all hear you all screaming through your laptops and mobile phones. Well, my evidence that lifting with stiffer, straighter spines doesn’t help reduce low back includes hundreds of thousands, if not millions of people over decades who have all been taught to lift things with stiff, straight backs, day in, day out at work.

The evidence I am talking about are the papers looking into the effectiveness, or rather I should say, the ineffectiveness of Workplace Manual Handling Training at reducing the rates of occupational back pain and injury.

So workplace Health and Safety Laws and compulsory Manual Handling Training was introduced in the UK over 50 years ago back in the early 1970s in an effort to protect employees from unfair and unsafe working environments and practices, as well as protect employers from high levels of employee absence and litigation due to workplace injuries. (ref)

These laws stated that all employers had to regularly educate and train all their employees, in both manual and non-manual based jobs on the importance and need for correct posture, workplace ergonomics and safe lifting techniques. This meant all employees are taught to lift anything weighing over 10kg close to the body and with a straight spine to avoid the risk of a back injury.

However, the unfortunate and unconformable facts are that these laws and this training haven’t reduced the incidence or prevalence of back pain or injuries in the workplace (ref). Now there are many questions as to why these workplace manual handling guidelines haven’t reduced rates of back pain or injury in the workplace, such as they weren’t adhered to by employees, or they were conducted properly by employers, or because back pain and injuries are multifactorial and not easily solved by simply asking people to pick things up a certain way.

Either way, the evidence tells us that Manual Handling Training that attempts to teach and train people to lift things with straight, stiff, neutral spines clearly does NOT reduce the risk, or rates of workplace back pain or injury significantly (ref, ref, ref). Yet it still continues on as if it does… this is utter madness… not to mention a day of my life wasted every year working in the NHS!

Burying Dead Bodies

So if keeping our backs stiff and straight when lifting things at work doesn’t significantly reduce our chances of getting back pain, what about when training at the gym? Or at home lifting the laundry basket? Or out in the woods trying to dispose of that pesky dead body you’ve had hanging around for a while? Well, the answer is… we just don’t know as there’s no substantial robust evidence either way.

However, I doubt that lifting technique is a significant factor in most back pains or injuries, in most people, most of the time. Even though a lot of back pain occurs when lifting, it doesn’t mean the lifting was the cause of the back pain. All back pain is complex and multifactorial, meaning it’s never caused by one, sole, isolated, independent factor such as how you lift something (ref).

Yes ok, lifting technique may have a part to play in some back pain, in some people, but if it does, it’s a small part, and usually the last contributing factor in a long list. For most people who hurt their back lifting there will be many other factors that contributed for far longer and far more, things such as their age, ability, strength, endurance, rest, recovery, capacity, capability, confidence, experience, exposure etc. All of these factors and many others determine if someone may or may not get an episode of back pain as they lift something.

When it comes to the risks of back pain and injury when lifting it may not matter that much how you lift things, but rather if you are ready and prepared to lift things, both physically and psychologically.

Lift With Your Back

It could also be argued that the constant advice to only lift with a straight back could be one of the reasons FOR the increasing amounts of back pain in our populations (ref). Constantly telling people to avoid bending, flexing, and twisting their backs under loads, can leave them weakened, deconditioned and under-prepared to tolerate these stress and strains when they inevitably occur in life.

It’s simply impossible, not to mention highly impractical, to avoid spinal flexion under loads and other forces such as shear and compression. It is, therefore, in my opinion, essential to prepare our spines to tolerate these loads and forces with gradual graded exposure to ensure they are robust and resilient.

Our constant advice to constantly avoid spinal movements outside of neutral is, in my opinion, a significant reason for the steady increase in chronic persistent back pain. I think all spines, in all people, need to be exposed to all movements, and all varieties of loads and forces, including spinal flexion when lifting things,

I think being exposed to and prepared for spinal flexion under load is both sensible and very much needed for many. However, as always there are exceptions to every rule, and I will admit that there are some people who find spinal flexion under loads to be painful and provocative and so avoiding this for a period of time to let it settle is sensible.

However, this avoidance should never be permanent, because for me the craziest thing any physio, coach, or trainer can do is ask someone to only do something, like lifting, one way all the time, forever. This would be like asking someone to only eat one type of food forever, drink one type of beer forever, or listen to one physio on the internet forever. This would be both disturbing and depressing and we would never dream of telling people this, so why is it any different with movement and exercises such as lifting.

Conclusion

So I hope you found this short read around lifting interesting, and I hope I have managed to convince or sway you a bit that simply educating, coaching, or telling someone to lift things with a straight back doesn’t automatically reduce their risk of back pain or injury.

So until next time… stay frosty… and remember you can’t go wrong trying to get strong… Now go lift something, those dead bodies ain’t gonna bury themselves!

Adam

Back Pain, Criticism, and Copyright!

Just in case you missed it, the latest physio brouhaha is now erupting on social media around some low back pain guidelines recently published that have come under a lot of criticism. This has also now devolved into arguments around tone, professionalism, but also academic copyright infringement.

This all starts with a tweet posted by the excellent Physio Meets Science Twitter account who consistently share and signpost therapists to many of the latest publications and research articles, if you don’t follow them go and follow them now. They recently posted a tweet that contained a link to an open-access clinical guideline on low back pain in a journal called JOSPT here and included three screenshots of the title page and two of the tables from this 60-page document (see below)

As you can see this tweet was ‘liked’ over 450 times and retweeted over 100 times, that’s some great engagement for a research paper, you might be thinking that JOSPT would be buzzing at all that interest and information dissemination. The tweet was also quoted tweeted by a few, myself included giving some thoughts and opinions on this guideline, some positive, some not so.

Now my own opinions were not that positive because on my initial quick scan of this guideline I thought this guideline was not very clear for the average physio (like me) who often skim reads these things and goes to the pretty pictures and tables to get a feel for the outcomes and results. I thought these had been very confusingly worded using a tiered system of SHOULD use, MAY use, and CAN use in their recommendations for specific treatments, and the tables had been poorly designed inferring a superiority of manual therapy treatment over and above other treatments, which when you dig down into the actual guidelines small print it actually doesn’t support (see below).

In my opinion, these clinical guidelines are often looked at by hard-working, time-strapped clinicians with at best mediocre statistical and methodology literacy, just like myself, to see if what they are doing is right and if there is any need to change or adjust their practice. Therefore I think it is imperative that researchers, authors, and publishers of these kinds of guidelines make their findings crystal clear and easy to read in a synopsis or table, and not bury the finer details or caveats in a small section of a massive 60-page document.

On further reading of the guideline, I also have other issues with it like the exclusion of some well-known back pain trials not being explained or justified clearly, not using the PRISMA or GRADE systems casting doubts about its methodological rigour, and separating ‘soft tissue mobilisation’ treatments which are claimed to be skilled techniques of moving specific tissues such as fascia and ligaments, from ‘massage’ which it states are general movements of the muscles alone. This ridiculous separation of basically the same treatments is both confusing and unnecessary, I mean just how the hell do you move muscles and not the fascia and vice versa

Anyway, I digress, so the comments and discussion around this guideline continued to develop and many others started to give more in-depth, specific, and skilled critical reviews of issues with this guideline. These threads again created more and more discussion and debate, but then suddenly these threads and the original tweet from Physio Meets Science disappeared and I was asked by some as to why.

Now I had no idea, so I reached out to Physio Meets Science and asked them why their tweet was deleted. They replied and told me that JOSPT had contacted them and asked that they delete the tweet for copyright infringement.

Now, this didn’t sound right to me as their original tweet included the link to the free available, open-access guideline and they only shared 2 images from the 60-page document, hardly breaching copyright rules if you ask me. I also had some messages from colleagues about rumours that someone was upset at all the negative attention and criticism this guideline was getting and had asked JOSPT for these tweets to be deleted. Now again this didn’t sound right to me and so I thought I would ask JOSPT directly if these rumours were true (see below).

The reply I got from JOSPT was firm and definite no and that tweets were asked to be deleted only due to copyright infringes.

However, I was still confused at this response because as I understand under ‘fair use policy’ copyrighted material can be shared publicly for the purposes of education, comment, discussion, and critique as long as the original source is fully referenced and no money or profit is being made. So I asked them twice if they could expand a bit more on what copyright has been infringed and why. But I got no response.

I did however get a direct message a few hours later from JOSPT now asking for my tweet to be deleted due to it infringing copyright, and advising me that I may only post cropped or partial images but must refrain from posting full figures or complete pages (see below)… PS: I’m also not a Dr.

So I then decided to seek some legal advice of my own from a past patient and now friend of mine who also just happens to be a very successful lawyer in the US to gain some clarification on copyright and fair use policy. After some checking, he came back to me and agreed that my tweet does not infringe copyright law. So I replied to JOSPT as such outlining my reasons and explaining that I will not be deleting my tweet.

Within a few hours of sending that message, I then received what I can only describe as an overly aggressive and condescending email from a JOSPT copy editor threatening legal action unless I deleted the tweet within 24 hours.

In this email, he stated that the fair use policy doesn’t apply to academic journals and is more for newspaper articles and book reviews, and only for comments that are written in a professional tone. He also went on to say that they are not asking some others to delete their tweets as their comments are professional and constructive in tone, whereas he thinks mine were not.

He also went on to state that the sharing of information on Twitter does NOT qualify as ‘educational’, which is just ridiculous, and that the screenshotting of full pages or images is not allowed. However, screenshots of partial or cropped images are, which I just don’t understand, I mean why is cropping images ok but not using a full one, and how much should they be cropped by, and what should be cropped?

So I replied that although I strongly disagree with everything stated I have neither the time, energy, or disposable income to get into a legal battle over copyright infringement, and so deleted my tweet under duress. I did explain that I am not happy about it or being threatened and shall be explaining and sharing what has happened and why my tweet has been deleted on my social media and with this blog, but so far I’ve had no further response from JOSPT.

So there you go, that’s the current situation with another physio online fracas… or #CopyrightGate if you will. I’m sure there is more to come on this and I haven’t heard the last. However, I’m both upset and annoyed at this whole fiasco of being threatened and labelled as a malicious and destructive force by JOSPT just for wanting to share my criticism of their guideline. And so I want to encourage further open and honest discussion and debate on this topic of copyright and sharing and dissemination of publications from both sides, journals, researchers, clinicians and the general public.

But for now, these interactions with JOSPT have done very little to reassure me that the rumours of attempted censorship and diversion away from negative comments and criticism are false. Unfortunately, I now find it very hard to believe that JOSPT asked for these tweets to be deleted solely for copyright infringement reasons and it leaves me with a very unpleasant feeling.

The current academic and scientific publishing industry has some major issues and it has come under some much-needed scrutiny and criticism lately. Not only do academic journals such as JOSPT have a monopoly on what gets published and how, they also get researchers and reviewers to work for them for free, charge extortionate fees to subscribers and institutions, and make huge profits that are not used for advancing of scientific endeavours rather line the pockets of corporations and shareholders.

But it now appears that some journals are also attempting to control and police what is discussed, debated and critiqued after publication. For a good insight into just how screwed up the current academic publication system is check out this astounding Twitter thread here by Cory Doctorow.

Personally, I feel this whole copyright enforcement debacle is being used intermittently and strategically when it suits some journals or their associates as a very thin disguise to manage, limit, or censor comments, suppress criticism, and divert attention away from certain publications. Because, when was the last time you heard of someone being threatened with legal action for sharing a publication or an image of an outcome graph or chart when it’s getting positive feedback and rave reviews?

As always thanks for reading, and let’s see if I get any further threats of legal action about this blog.

Adam

Back Pain Sucks!

As you may know, I recently had an acute episode of low back pain with some left leg radiculopathy when deadlifting a few weeks ago. As painful and frustrating as this was I thought it would be a great opportunity to document and share my experiences of the ups and downs of an episode of back pain and you can watch this on my Instagram page here.

This journey has been a painful, stressful, and frustrating one, but also an enlightening experience that has highlighted and re-iterated some important things for me. The first and most important thing is never underestimate just how bloody hard it is to tolerate and endure severe pain for extended periods, nor how easy it is to worry and think the worst about what’s causing it, and if it will get better.

Knowledge without Experience is Bullshit!

Despite my training, knowledge, and 20+ years of clinical experience managing people with all types of pain, and knowing that the research shows many episodes of back pain and radiculopathy improve favourably over time. There is NOTHING like some first-hand experience of living with searing, unrelenting neuropathic pain to really put things into perspective about how this information doesn’t make things feel any better or stop you from worrying any less.

Despite knowing things heal and recover with time, I didn’t care that much at 3 am in the morning whilst lying on the living room floor trying to find a position that eased my agonizing leg pain a little. Despite knowing my pain will improve and my prognosis is good I still had doubts, concerns, and occasionally thought the worst.

These last few weeks of severe pain, lack of sleep, and bone-deep fatigue have hammered home that if I’ve struggled to reassure myself at times, just how good am I at reassuring others? This episode has also reminded me that when pain is severe, constant, and unrelenting it can take control of you and your thoughts, and no matter how tough, resilient, or double hard you think you are it adversely affects you.

Cringe!

I cringe a little now when I think back to the times I have tried to reassure those with similar pains to mine, by carefully and compassionately explaining how they have no signs or symptoms that indicate they have anything to worry about or need further imaging or invasive treatments. And how they will feel a lot better in a few weeks and should try to reduce and control their pain with some simple exercises, a bit of analgesia, hot or cold packs, and by staying as active as much as possible.

This recent painful episode of mine has made me think, how effective was/am I doing this, and does it actually help anyone? Well, judging by some of the messages I’ve received it seems that it does as many have told me they found it really useful to hear me talking about these feelings and emotions publicly, and by simply acknowledging and normalising these doubts and concerns it has helped others understand that it is perfectly normal and natural to have them as well.

I have also been really grateful for all the kind, encouraging, and supportive messages I have received over these last few weeks as these have really helped me stay positive and motivated through some tough times. These messages have also re-iterated to me just how important and useful some simple, honest, kind, genuine, support, and encouragement can be when you’re in pain, tired, frustrated, and thinking the worst.

Positive and Negative!

However, what I haven’t enjoyed, nor was I expecting when sharing my updates were the number of attacks, accusations, and nasty comments I got from others. Don’t get me wrong, I’m not naïve enough to think I wouldn’t get any, as I know you can’t put anything on the internet these days without some troll posting something hateful, and I’m well aware that I’m not everyone’s ‘cup of tea’ rubbing many up the wrong way with my views and opinions on things.

But I did not anticipate that I would get so many nasty, snide, and snarky comments from so many so-called kind, caring, and compassionate clinicians who are clearly revelling and rejoicing in my current predicament. Again, don’t get me wrong, I expected and hoped for some piss-taking and teasing, but never did I think so many would be so excited to see me hurt or use this episode as an opportunity to attack me and my reputation.

During these last few weeks, I have been accused of being unprofessional, inexperienced, and a shit physio, and these are just the comments I have seen as I’m also told many more have been said in closed forums and private social media groups. It seems that some turd juggling wassocks out there think physios should never get back pain or be injured, and if they do it somehow means they are less skilled or knowledgeable than others. I guess this also means these useless fart bubbles think doctors shouldn’t get sick, surgeons shouldn’t need operations, and professional athletes shouldn’t get injured either.

You Deserve It!

I have also been told by some so-called ‘therapists’ that I deserve my pain and have earned my injury with my reckless approach to training and terrible lifting technique. This is even though theres no evidence that any lifting technique increases or reduces the risk of back pain (ref) heavy lifting is not a common cause of discogenic back pain (ref), and this is my first significant lifting related injury in nearly 30 years of continuous deadlift training whilst doing a near-maximal effort 2.5 x bodyweight lift.

It seems that these arse biscuits think all injuries are avoidable and if you do get injured when exercising it’s your own fault. These mouth breathers also seem to think their so-called perfect form and correct lifting technique they demonstrate with less than bodyweight loads is the solution to the prevention of all back injuries.

Well, newsflash bell ends, anyone can maintain a pretty looking posture when they lift light-weights, but trust me it will soon turn ugly when you increase the load or the intensity, which they would know if they actually did that from time to time. What these comments highlight is just how many dumb arsed therapists are completely oblivious to what heavy intense exercise looks and feels like.

When these idiots expect everyone to move the same way lifting heavy-weights as they do lifting light-weights, they are as clueless as someone who thinks a runner should sprint the same way they jog. These clowns fail to recognise that all movement is complex and hugely dictated by the task which includes the loads, speeds, intensities, and complexity and that all injuries are multifactional and never due to a sole factor alone.

Yes ok, maybe higher loads, speeds, and intensities may have higher injury risks, and yes, you may reduce these risks by reducing loads, speeds, and intensities, but don’t kid yourself for one second into thinking this eliminates it.

Fearful Physios

These comments also demonstrate how fearful and risk-averse some therapists are to exercise and training. Don’t get me wrong I’m all for being sensible and I do like to build things up steadily and progressively in most people for most things. But to think you should always move the same, or always avoid high loads, high speeds, high intensities to avoid injury is both ignorant and impractical.

During these last few weeks, I have also been accused of being in denial, stubborn, ignorant, arrogant and some more colourful things ending in ‘T’ for not getting assessed or having a particular type of passive treatment for my pains. Some of these odious little cretins have even tried to accuse me of being dangerous and reckless, and even tried to blame me for making my symptoms worse, despite them improving, as well as the growing global back pain epidemic.

It seems that these dripping dishrags think a physio with 20+ years’ experience who has read widely around pain, pathology, and its treatment cannot make a rational, informed clinical assessment and judgement of their own condition. And it seems some of these egotistical flap dragons think that they can assess and manage me across social media from thousands of miles away far better than I can manage myself.

Heal Thy Self!

And to those who think they are being clever by quoting ‘a physician who treats himself has a fool for a patient’ also need to shut the hell up because physicians can and do treat themselves when they have signs and symptoms of simple common illnesses. And just as a physician can recognise the signs and symptoms in themselves of simple common illness that has favourable natural history, doesn’t need further investigations or interventions, so a physio should be able to do the same with a common and simple musculoskeletal injury or pain.

What these comments highlight is just how many therapists do not understand normal healing and natural resolution times, and how they do not, or cannot accept that there are many people who do not want treatment straight away, who are happy to wait and see how things go, and who can carry on despite their pain rather than rush to reduce or remove it.

These comments also highlight how arrogant and insecure many therapists are in not wanting to accept or admit that they are not needed as much as they think they are, or the reason why many of those they see and ‘treat’ get better with it often instead just time working in the background.

All these accusations and attacks also highlight how petty and pathetic some can be when they see others saying or doing things they disagree with, and how some have very delicate and fragile egos combined with large inferiority complexes meaning they quickly get jealous, vexed, and bitter towards anyone who questions what they do or achieves more than they have.

Conclusions

Finally, this back issue of mine has confirmed to me yet again just how much variation there is in physiotherapy practice, with so many different opinions, ideas, and suggestions of tests, investigations, and treatments for something as common and relatively ‘simple’ as an acute episode of low back pain with a touch of radiculopathy.

As much as I understand variation in all things is often a good thing as it gives options, if we as a profession can’t agree on some simple core principles of who, how, and what to do for the most common musculoskeletal issues, then we are in serious trouble. Because as much as I know, there is variation in other areas of healthcare such as medicine, and many doctors have many different ideas, opinions, and suggestions about how to manage something like a common cold, I’m sure all would agree that a common cold doesn’t need complex assessments, unnecessary investigations, or regular expensive treatments.

Until we can get a better handle on this variation within physiotherapy there is only going to be increasing confusion and chaos around our assessments and treatments, which I fear will lose us the trust and respect of not only other healthcare professionals but also the public. And if we lose the trust and respect of the public physiotherapy will be quickly pushed out to the fringes of healthcare along with the other quacks and nutjobs who claim miracle cures and quick fixes with their trinkets and charms.

As always thanks for reading

Adam

SPECIAL ANNOUNCEMENT

If you would like to learn more about an evidence-informed, no bullshit approach to the assessment and management of low back pain then I am running a short webinar on Tuesday 28^th Sept at 7pm BST.

To find out more or to reserve your place please click the image below or this link here