Sitting and Back Pain
A number of years back I wrote an article on sitting and back pain…actually it was on this page before I changed it entirely. (You can view the original article at the bottom of this page) I had based the article on what I had been taught and what I had believed I had observed over the 20-plus years as a manual/myofascial release therapist and nearly 30 years as a physical therapist. Whenever I check my blog statistics page, this page is always at the top in terms of daily views. People around the world have read what I wrote and came away informed…sort of. Traditional logic (actually, internet logic) says that prolonged sitting leads to shortening of the hip flexors (iliopsoas) and shortened hip flexors lead to an increase in anterior pelvic tilt and lower back pain. I used to recite that mantra to nearly every patient who had lower back pain. The kicker was that when I did myofascial release treatment to address what I thought was short hip flexors, my patients nearly always improved. So if the “sitting shortens the hip flexors and tight hip flexors lead to an increase in anterior pelvic tilt and lower back pain” logic is false, what IS happening? What I did/do with my hands, when I am in treatment, apparently had little to do with what I thought that I was accomplishing.
Todd Hargrove, in his Better Movement blog, wrote a few articles titled “Does Excessive Sitting Shorten the Hip Flexors?” as well as “Does Anterior Pelvic Tilt Cause Low Back Pain?“. (Thanks, Todd, I like the way you think and write) He pretty much dispels all of these myths quite succinctly. There is simply no plausible evidence that any of these conditions lead to an increased incidence of lower back pain. These facts do not negate the positive outcomes that I have had over the years treating issues that I believed existed, it just shows me that there are other things happening under my hands that need to be better explained.
When I interview a new patient with lower back pain complaints, I ask them a few very specific questions. I ask them to distinguish between extended sitting with their back relaxed against a chair back with sitting while leaning forward, as if working at a computer. They will typically answer that the second scenario is more problematic. I will also ask them if prolonged standing, especially with a slight forward lean (as if standing at the kitchen sink, washing dishes) increases their low back pain. My patients will often answer in the affirmative for this questions as well. My takeaway was that there was shortening of the hip flexors, which I would attempt to objectify through a test of hip flexor length (Thomas Test). I would then perform some gentle palpation to the region of the hip flexors while my patient relaxed in supine. Many times these tests would reproduce the pain, all of which brought me to my stunning conclusion that the hip flexors were at fault. No harm done, as for nearly 20 years I did not know any different, or ignored those who told me different. I would then do what it was that I do with all of my patients, myofascial release treatment, and they improved.
I do not have the full answers as to why when gentle treatment is applied to the areas in the region of the hip flexors/anterior lumbar area; lower back pain lessens or goes away. I now believe we are looking at the effect that we have on the entire nervous system. This region is richly innervated with nervous tissue, from the superficial cutaneous nerve, which by itself possesses the ability to modulate the type of changes we see, to the deeper nerves of the lumbosacral plexus. I am curiously exploring these models of explanation and enjoying the realization of how wrong I was in the past. Don’t change what you do, change how you think. When you think in different ways, what you do may then change for the better!
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Sitting and Back Pain (Old version, 2009)
For many people, sitting poses no problem at all. Sitting in any position for any length of time produces no ill effects. However others are not so lucky, as sitting for even short periods can be painful. The pain may occur while they are sitting or afterward, when they try to get up to stand and walk. Many, many variables can create these conditions of pain, so trying to generalize regarding prevention and treatment can be difficult and potentially misleading. Being aware of your options can create a huge shift in the pain that you suffer.
We are constantly being told what a correct sitting posture looks like. These images tend to be one of the buttocks pulled back into the chair back, a mild lumbar curve in the small of the back (often supported by the lumbar support of the chair or a lumbar cushion), and feet flat on the floor. You may strive for this posture, but continue to suffer back pain during and after prolonged sitting. Next, you might purchase an ergonomically correct chair with no real change. What might be missing?
In my practice, when a patient is experiencing back pain with sitting or coming up to stand after sitting for a period of time, I always pay close attention to the hip flexors (psoas). The function of the hip flexors is to…flex the hips. When you stand or lie down and contract the hip flexors, your thigh will move up toward head. However, if there is shortness of the hip flexors, due to the upper attachments of the hip flexors, standing will cause the low back and pelvis to pitch forward. When lying on your back the shortness will increase the arch in your low back. Both of these scenarios frequently lead to back pain and even more serious disorders of the discs. So where does sitting fit in?
Numerous studies have show that sitting creates more pressure in the discs of the spine than does standing. Further, sitting with the trunk pulled forward over the hips (as in leaning forward while working at a computer) creates more pressure than sitting with your back against the chair back. Opening the hips into a more open angle (reclined back) further decreases the pressure in the discs. A great summary of some of these findings can be found here. Also, when you sit with your back and pelvis forward for a length of time, the hip flexors will shorten. Returning to stand will pull on the lumbar spine and discs, eventually leading to failure and pain. Thus, the shortness of the hip flexors can create back pain when arising from sitting and improper sitting posture can create an increase in pressure of the discs. Neither scenario is desirable.
While many resources exists (both in print as well as on the internet) that address various views on proper sitting posture, few address the background muscle tone that takes place while a person sits on various surfaces. One very important topic that I address in my practice is the amount of contraction that the hip flexor assumes during sitting. If the hip flexor is held in a contracted state for extended periods of time, one will experience difficulty coming to stand, not to mention the long-term changes that can take place in a muscle that shortens over a period of time. Given the attachment of the hip flexor to the lumbar spine and discs, these are issues that are vital to back health and comfort, both short and long term. Altering your holding patterns while sitting can reap great benefits, both for comfort as well as for long-term diminishment of back pain.
At the Pain Relief Center, I take care to address both the shortness of the hip flexors as well as educating you on how to hold your body for maximum relaxation of these very important areas.
You can find out more about a more science-based approach to Myofascial Release by checking out Foundations in Myofascial Release Seminars.