– “It hurtsh when I sh!t”.
– “Sorry, it hurts when you..?”
– “When I sh!t”, he quickly interrupted. “You shee? Like thish”, as Adriaan, an elderly dutchman took his seat in the clinic and continued to describe his low back pain. “It painsh in my shpine when I sh!t like thish”.
I suddenly remembered a post-match interview with Louis van Gaal, the former Dutch and Manchester United football manager. “Ah when you sit! Of course. It hurts when you sit”.
There are occasionally moments during clinical assessment that can be embarrassing, sometimes for the clinician, other times for the patient. Should I confess that the real reason for my back pain was trying to replicate some of the recent Rio Olympics gold medal performances after a few beers? Or will I just go with the standard text-book type reason; the one google said was the most common cause of what appears to be my problem. Having as much relevant information as possible during that consultation however can often provide the clinician with what they need to know to make a differential diagnosis. Often the diagnosis can be made from the history taking alone long before even examining the patient. People with back pain will often report their problem to be aggravated by sitting, particularly sitting for prolonged periods of time. And sitting gets a bad name when it comes to low back pain. Often times it’s guilty as charged but lets get a few things straight here. The act of sitting itself is usually not the problem. Our spines are designed to be able to sit. We’ve always sat. From back in the caveman days right up until now. But the spine is also designed to move and go the opposite direction, albeit to a lesser degree. It is the length of time spent in this seated position that can lead to problems.
“You’re most important posture is your next posture”
“You’re most important posture is your next posture”, a recent statement I came across online. And how true. What does it mean? It guess it means keep moving. But with todays workforce that is proving to be more complicated than it should. Research suggests that 75% of the work force in industrialised countries are in sedentary jobs, i.e. spending most of their days sitting down (Reinecke et al 2002). And of the working population 60-80% will report back pain at some stage in their lives. So lets take a hypothetical scenario of a typical sedentary job in Ireland in 2016: Tim is an accountant living in Portlaoise, travels 90 minutes to Dublin in the morning, spends 9 hours at his desk throughout the day interrupted by a coffee break 3 hours into his working day, lunch a further 2 hours in (still sitting), and 2-3 toilet breaks before returning home that evening in 2 hours of traffic. A grand total of 12 hours sitting. We used to think that 30-60 minutes of moderate to vigorous activity during the day at some stage was enough to counteract this but research would now suggest this is not the case. It has reached catastrophic levels where we need to start incorporating periods of non-sitting during the day.
So how do we overcome this in a world where we are spending more and more time at work meeting deadlines and the pressures of modern day life? Gym balls are a nice option to sit on. This will at least mean there is some corrective contraction going on around the core. Yet it is still sitting. Stand up desks have emerged on the market that give the option of sitting, standing or perching on a stool during the day as well as the option of adjusting the height of the computer in search of that ‘perfect posture’. It follows the principle of not staying in any one position for long durations – simple, and effective. An Irish company, miDesc , has recently launched their product and is sure to draw attention here and over seas. Other similar desks have been trialled in America showing a more productive workforce, and in schools a more attentive classroom. Traditionally children enter the school system and are trained into this structured sedentary setting from infancy, gearing them up for a lifetime of sitting. The World Health Organisation predicts that Ireland will be the worlds most obese nation in 16 years and it is clear to see how. But lets park back pain for a second and look at the bigger picture. Physically active people have 50% lower risk of functional limitation. They have a 40% lower death rate (World Confederation for Physical Therapy, 2016). Surely another couple of reasons worthy of acting on.
What about that perfect sitting position? Or the executive chair designed to fit the contours of your spine? The one you came across on the Shopping Channel early one morning before work. You’ve shown your boss the brochure and how it would benefit you. But they are still hesitant to make the purchase. And they would be right. A more productive workforce is an active workforce. It is why the big multi national companies will provide staff with exercise facilities, run exercise classes, encourage walking meetings where the conversation had during a brisk lunch time walk may trigger an idea for later that afternoon. A healthier workforce will be less likely to miss work on sick leave or be stressed. The big companies know this. Despite claims, that perfect sitting position actually lacks sound evidence. Awkward sitting postures in positions involving whole body vibration such as machinery work has been shown to increase the incidence of low back pain (Lis et al 2007). Yet there are people who slouch for periods who do not experience back pain. More established risk factors for low back pain are higher body mass index (BMI), and previous history of low back pain, at least one of which we know is very modifiable through exercise.
So the case of Adriaan made me think. The waiting area in my clinic is like most waiting areas; welcoming, some information leaflets, pictures, seats etc. But I now encourage patients, where appropriate, while they are waiting to get started with some of the exercises they will have been prescribed on their last visit. Because why should someone with back pain attending for physiotherapy be doing the very activity that exacerbates their problem while they wait?
For more information on any of the issues addressed throughout this article please contact Rob via email at firstname.lastname@example.org, Twitter @mccabephysio, Facebook at McCabe Physiotherapy or visit http://www.mccabephysiotherapy.com
Rob McCabe MISCP
MSc (pre reg) Physiotherapy, BSc Sport Science and Health, MSc Sports Physiotherapy, PG Dip Orthopaedic Medicine
Orchard House, Moorefield Rd, Newbridge, Co. Kildare