Back pain – ‘Bad’ posture is not the villain

Feb 22, 2023

We have probably all suffered a bout of back pain in our lifetimes, more commonly in adulthood. Usually, it is a one-off. However, back pain is the leading cause of disability worldwide. For 25% of people who develop back pain, it can become persistent, disabling and distressing. Activities such as sitting, standing, bending and lifting frequently aggravate back pain.

Every day we see articles, products from lumbar rolls to contraptions that will pull your shoulders back, with the underpinning belief that “good” posture is important to protect the spine from damage, as well as prevent and treat back pain. Good posture is commonly defined as sitting “upright”, standing “tall and aligned”, and lifting with a squat technique and “straight back”.

Conversely, “slump” sitting, “slouch” standing and lifting with a “round back” or stooped posture have been vilified. This view is widely held by people with and without back pain, worryingly, this is still the message being occupational health (manual handling training sessions) and primary care settings.

We must address the facts. There is a lack of strong evidence for a relationship between “good” posture and back pain. It is important to state that studies have found ergonomic interventions for workers, and advice for manual workers on the best posture for lifting, have not reduced work-related back pain.

Back pain and posture - the jersey sports and spinal clinic

Sitting and standing posture 

One of the leading researchers and authors on the topic of back pain is Dr Peter O Sullivan. He is both renowned and highly regarded in medicine. He and colleagues conducted several studies exploring the relationship between spine posture and back pain. They investigated whether “slump” sitting or “non-neutral” standing postures (overarching or slouching the back, for example), in a large population of adolescents, were associated with, or predicted future back pain. They found little support for this view. 

These findings are consistent with studies that have found no consistent differences in sitting or standing posture between adult populations with and without back pain. 

People adopt a range of different spine postures, and no single posture protects a person from back pain. People with both slumped and upright postures can experience back pain. 

Lifting posture 

Globally accepted occupational health practices about “good” or safe back postures during lifting also lack evidence. Our systematic review found no evidence lifting with a round-back posture is associated with or predictive of back pain. 

Our recent lab study found people without back pain, employed in manual work for more than five years, were more likely to lift with a more stooped, round-back posture. 

In comparison, manual workers with back pain tended to adopt more of a squat lift with a straighter back. 

In other words, people with back pain tend to follow “good” posture advice, but people who don’t lift in the “good” way don’t have more back pain. This is quite alarming to some as it flies in the face of their beliefs. 

In a small study, as people with disabling back pain recovered, they became less protective and generally moved away from the “good” posture advice. 

If not posture – what else? 

There is no evidence for a single “good posture” to prevent or reduce back pain. Our spines come in all shapes and sizes, so posture is highly individual. Movement is important for back health, so learning to vary and adopt different postures that are comfortable is likely to be more helpful than rigidly adhering to a specific “good” posture. You will have heard us say regularly “ your best posture is your next posture”. 

While back pain can be intense and distressing, for most people (90%) back pain is not associated with identifiable tissue damage or pathology. This is often the case when those suffering with pain undergo an MRI or x-ray.  

The science is clear when we have other factors rumbling in the background, this is a larger factor for back pain. This can be if someone perceives they are too stressed, are feeling low, tired/fatigued, have poor activity levels, or are unhappy at home or work.  

Back pain is more likely to persist if a person becomes overly worried and fearful about their back pain and consequently overprotects their back and avoids movement, physical activity, work and social engagement. 

As part of your assessment with the team at The Jersey Sports & Spinal Clinic, we will explore the reasons for your pain and devise a personalised plan with you to help you get back on track and achieve your goals. 

 What can people do about back pain? 

In a small group (1-5%), back pain can be caused by pathology including a fracture, malignancy, infection or nerve compression (the latter is associated with leg pain, and a loss of muscle power and sensation). In these cases, seek medical care. 

For most people (90%), back pain is associated with sensitisation of the back structures, but not identifiable tissue damage. 

In this situation, too much focus on maintaining “good” posture can be a distraction from other factors known to be important for spine health. 

These include: 

  • moving and relaxing your back 
  • engaging in regular physical activity of your preference 
  • building confidence and keeping fit and strong for usual daily tasks 
  • maintaining healthy sleep habits and body weight 
  • caring for your general physical and mental health. 

Sometimes this requires some support and coaching with a skilled clinician. 

So if you are sitting or standing, find comfortable, relaxed postures and vary them. If you are lifting, the current evidence suggests it’s OK to lift naturally – even with a round back. But make sure you are fit and strong enough for the task, and care for your overall health. 

Adapted from The Conversation: August 17 2022. Authors: Prof Peter O’Sullivan, Prof Leon Straker, Nic Sareceni