Back Pain Myths: Posture, Core Strength, Bulging Discs

Spine and Disc
Problem?

It is an article of faith among many mainstream experts that poor posture, lack of core strength, and/or structural abnormalities such as bulging discs are major causes of pain, especially back pain. A further assumption is that by working to correct such imbalances, through stretching or strengthening regimes, or surgery, the imbalances can be corrected and pain will decrease. It is probably fair to say that the majority of physical therapy and corrective exercise done in this country is based on exactly these assumptions. Although these ideas have a common sense appeal, there is significant evidence questioning this approach. Here’s a brief review of the conflicting evidence.*

Posture

You have probably heard the claim that bad posture causes back pain, or that you should try to improve your posture to get rid of low back pain.

You can find this claim all over the internet – from physical therapists, chiropractors and personal trainers. If you do a Google search for “posture and pain,” you get 4 million hits.

With so many posture police on patrol, it is a near certainty that you will sooner or later be told by some authority that your posture needs work.

For example, if you go to a physical therapist with low back pain and a large curve in your low back, you may be told that you need to correct this by sucking in your gut, squeezing your glutes, tucking your tail, or strengthening your core. If you have upper back pain and a sunken chest, you may be told to pinch back your shoulder blades, strengthen your scapular retractors, stretch the chest, and raise the sternum.

These ideas have intuitive appeal, and are advocated by numerous experts. But are they supported by evidence? And should you spend time trying to analyze your own posture and make corrections? Let’s look at some evidence that might help us answer these questions.

In one study, researchers looked at the posture of teenagers and then tracked who developed back pain in adulthood. Teenagers with postural asymmetry, thoracic kyphosis (chest slumping) and lumbar lordosis (overly arched low lack) were no more likely to develop back pain than others with “better” posture.

Another study looked at increases in low back curve and pelvic angle due to pregnancy. The women with more postural distortion were no more likely to have back pain during the pregnancy. A systematic review of more than fifty four studies found no good evidence of a correlation between posture and pain. Leg length inequality seems to have no effect on back pain unless it is more than 20 mm (the average leg length difference is 5.2 mm). Hamstring and psoas tightness do not predict back pain.

These results are particularly striking given that many studies have quite easily found other factors that correlate well with low back pain, such as exercise, job satisfaction, educational level, stress, and smoking. Although some studies have found a correlation between back pain and posture, it is important to remember that correlation does not equal causation. It may be pain is causing the bad posture and not the other way around. This is a very likely possibility. People will spontaneously adopt different postural strategies when injected with a painful solution. Big surprise!

Based on the above, there is little evidence to support the idea that we can explain pain in reference to posture or that we can cure pain by trying to change posture. For more articles on posture, click here.

Disc Degeneration and Other MRI Abnormalities

Another common idea is that herniated discs or other degenerative changes revealed by MRI are major causes of back pain. Many people who learn of these structural changes will assume it is the cause of their pain and start to consider surgery as a solution.However, numerous studies show that many types of structural abnormalities are poor predictors of pain.

In one famous study, MRIs were performed on subjects who did not have back pain. Fifty two percent of the subjects had at least one bulging disc or other MRI abnormality for which surgery is sometimes recommended. Given these findings, the authors stated that: “the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.” In a similar study, MRIs on individuals who had never suffered from low back pain revealed that one third had a substantial spinal abnormality and 20% under the age of 60 had a herniated disc.

In a study of pain free hockey players, seventy percent were found to have abnormal pelvis or hip MRIs, and fifty four percent had labral tears. The author stated that “this study shows the limitations of depending too heavily on an MRI. A surgeon may see something in the image, but it isn’t causing a problem.”

In this study, researchers examined forty four volunteers, age 20-68, with no history of knee pain. Sixty percent showed abnormalities in at least three of the four regions of the knee, causing the authors to conclude that “meniscal degeneration or tears…are highly prevalent in asymptomatic individuals.”

Studies of active baseball pitchers or overhead athletes consistently demonstrate very large percentages (over seventy percent) of torn labrums and rotator cuffs.

These are all issues for which surgery is sometimes recommended.

This is not to say that herniated discs, torn labrums or other structural abnormalities cannot cause pain. Of course they can, and you would rather have less damage than more. But if a large percentage of pain free people have bulging discs, then how likely is it that a bulging disc is the cause of your back pain? If you look close enough at almost any joint in the body, you will find something wrong with it. Don’t assume that whatever shows up on the MRI is the source of your pain. For more on the poor correlation between MRI results and pain, click here.

Core strength

The idea that good core strength is essential for a healthy back is another ubiquitous idea. What is the evidence that poor core strength causes pain or that core strength exercises reduce back pain?

Before reviewing the studies, it is first interesting to note that most of life requires only minimal activation of the core musculature. During walking, the rectus abdominis has an average activity of two percent of maximal voluntary contraction, and the external oblique operates at five percent. During standing, trunk flexors and extensors are estimated to fire at less than one percent. Add more than fifty pounds to the torso and they fire at three percent. During bending and lifting muscular activation is similarly low. Given that daily life seems to require so little core strength, perhaps it is not surprising that research interventions to increase core strength have little effect on pain.

For example, one study showed that core strengthening exercises for pain free persons identified as having a weak core do not reduce the future likelihood of back pain. Numerous studies have been performed to test whether core strength exercises reduce back pain. The thrust of these studies is clearalthough these exercises can improve low back outcomes, it works no better than general exercise. The obvious conclusion is that if core strengthening has any benefit at all, it works only because of the generally beneficial effects of exercise (or as a placebo), not because the core is a special area of concern. In other words, despite what we are told over and over, the current evidence states that there is nothing magic about core strength as means to prevent or reduce back pain.

Conclusions

The above results are surprising and counterintuitive, and raise many questions such as: why do these approaches seem to work; how can so many people be wrong; and if these aren’t the true sources of pain, then what is?

For more information to answer some of these questions, I recommend clicking on the Posture and Pain links above for relevant articles, in particular the following:

Seven Things You Should Know About Pain Science

Five Misconceptions about Posture

Three Essential Elements of Good Posture

Paul Ingraham’s Tutorial on Low Back Pain

Does Sitting Shorten the Hip Flexors

Does Anterior Pelvic Tilt Cause Back Pain

The Complexity of Biomechanics 

Review of Conference on Pain and Motor Control with Lorimer Moseley, Parts OneTwoThree, and Four.

*Most of the studies referenced in this article are from three excellent papers: The Myth of Core Stability by Eyal Lederman; The Fall of the Postural Structural Model in Manual and Physical Therapies by Eyal Lederman; and The Traditional Mechanistic Paradigm in the Teaching and Practice of Manual Therapy: Time for a Reality Check, by Frederic Wellens.

 

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75 Responses to Back Pain Myths: Posture, Core Strength, Bulging Discs

  1. Matt Metzgar says:

    Todd,

    Have you read that article, “The Myth of Core Training”?

    • Todd Hargrove says:

      Matt,

      Thanks for stopping by. I’m not sure I have read that one. The research in my post is mostly from a great article by Eyal Lederman called the Myth of Core Stability.

  2. Paul says:

    Hi, Todd. Nice post. You’d probably appreciate one of my articles on this topic:

    http://SaveYourself.ca/structuralism

  3. Glenn says:

    Todd,
    I’m always interested in, and enlightenedy by, your postings… even when I think I disagree. As you say, it certainly seems to make sense, from an observational point of view, that, e.g., tight hip flexors and weak glutes from excessive sitting would cause pelvic anterior tilt, leading to low back pain. In my own case, mild back pain from walking uphill stopped completely not long after I switched to a stand-up desk.
    Is there something special about the back such that structural imbalances are not the cause of pain, when in other parts of the body they obviously are (e.g. bursitis from internally rotated shoulders)?
    I’ll definitely look into those studies you mentioned.

    • Todd Hargrove says:

      Glenn,

      Thanks for the comments, appreciated as always. I agree its hard to believe structural issues don’t seem to matter much in the studies. Once I learned a little more about pain science it made a little more sense. I will discuss it in the next post, but the basic idea is that pain is an output from the brain, not an input from the body to the brain. The brain has quite a bit of discretion in deciding when you will feel pain, and its outputs in this regard are very individual and idiosyncratic and depend on many factors aside from the condition of the body, such as emotions, past experiences, future needs, etc. And that applies to the shoulder just as much as the back.

  4. […] Back pain myths. Read and share your thought, just something to think about. […]

  5. Glenn says:

    I look forward to the next post!

    While all of this fascinates me, I can’t help thinking of how much the brain-centered approach you explicate reminds me of when I was kid. My Dad–a tough guy from the old country (Germany)–used to dismiss my minor injuries and pains by saying “Eh… it’s all in your head.” That was fine, until I actually fractured my ankle!

    Maybe its because I have lots of friends who are natural bodybuilders, and because I do powerlifting myself, that I appreciate the incredible role that the mind plays in the mind-muscle connection. But at the same time I see that bones, ligaments, tendons, fascia, and muscle have a palpable size, integrity and, well, structure, that the brain can’t simply change at will. But there’s definitely a lot more to all this that we need to think about!

    Thanks for making us think and wonder.

  6. Todd Hargrove says:

    Glenn,

    Its true, pain is all in your head, but not in the sense that it isn’t real. Pain is real. And yes, the body is important too, you will never lift a lot without a strong structure.

  7. Tim says:

    Fascinating. I have pain in my lower back, but only when I run a lot. I also have pain between the shoulders and in the neck. So I’ve started my quest to find out why this is.

    I’ve been to chiropractors and physical therapists and they either have no idea what to do or say that I should strengthen and stretch certain muscles. I’ve not really bought the strengthening/stretch theory so I’ve continued exploring new therapists that might have other ideas. Right now I’ve met a therapist that practices the Feldenkrais method. I’ve decided to give it a serious try. Do you know much about Feldenkrais? What do you think about it? Atleast it seems to be more about the nervous system than about strengthening and stretching.

    I’m definately looking forward to your next post.

    • Todd Hargrove says:

      Tim,

      Sorry to hear about the pain. I am a big fan of feldenkrais and in my second year of training to be a practitioner. I have several other posts which discuss the Feldenkrais method. My take is that FM aims directly at the nervous system and therefore has a better chance of hitting the target than stretch and strengthen regimes, which aim at the mesoderm. Good luck!

  8. ian stevens says:

    Todd , you make some excellent points…If you go to a physical therapist with back pain and a midsection that is any less impressive than an Olympic gymnast, it is a mortal certainty you will be told to strengthen your core.
    Brilliant! However every ‘fitness’ magazine seems to have a man lifting up his tee shirt to expose such an abdominal wall…bizarre

    I am a UK physio therapist with the emphasis on the latter ….I have been communicating with Eyal Lederman for many years. His work , articles and books are excellent but they are like much of this stuff counter cultural. Biomechanics is simplistic , it makes sense to most people, both in the general public and in much of medicine but as Paul has written -its usually wrong!
    You might be interested in Sandra Blakeslees very readable book on body mapping which is the missing link for explaining a lot of therapeutic input in my opinion.
    Great work

  9. […] I think you’ll find these two blogs interesting as they dispel some rumors! Check them out here and […]

  10. Mo says:

    Todd – looking forward to your next post because I have a central bulge at L4-L5 and get shooting pain down my legs. I am getting a cortisone shot in a few days. Things have been getting better, but it can, at times, be debilitating.

  11. […] Know About Pain Science June 24, 2010 Todd Hargrove Leave a comment Go to comments In the previous post I discussed some common back pain myths, such as the ideas that bulging discs, “bad” posture, […]

  12. […] Back Pain Myths: Posture, Core Strength, Bulging Discs « Better … […]

  13. […] Strength Squat WOD 3 Rounds 15 Pullups 30 Overhead Lunges CF Football Here CF Endurance Here Back Pain Myths: Posture, Core Strength, Bulging Discs Out with the Vibram Five Fingers and in with the Soft Star RunAmoc Funny Sights at a Globo Gym, pt […]

  14. […] Back Pain Myths – Todd Hargrove Squatting is Not Optional – Lisbeth Darsh var a2a_config = a2a_config || {}; a2a_config.linkname="Fri, Jul 9th"; a2a_config.linkurl="http://crossfit.ie/2010/07/09/fri-jul-9th/"; […]

  15. […] Core Strength August 10, 2010 Todd Hargrove Leave a comment Go to comments In a recent post I argued that there exists very little scientific evidence to justify the massive emphasis on core […]

  16. Marc says:

    Todd,

    GREAT post! I was going to ask you if Feldenkrais “jived” with this ectoderm approach. But then just read all the comments and got my answer ;-)

    In all my years of going to seminars, workshops, accupuncture school, etc etc….I was most impressed with Feldenkrais. One of my very high level martial arts teacher who was from Israel, introduced a bunch of us to some basics. It was eye opening.
    Again great post.

    Marc

  17. […] who do not.  But that is not what the preponderance of the studies find.  As summarized in a previous blog post, the weight of the evidence is that people with bad posture are not more likely to have pain than […]

  18. […] gets scarred and stiff. As I stated in an earlier post, it is very possible and even likely that these structural problems will not result in pain, but this will depend on the brain’s ability to start sensing and moving the altered body parts […]

  19. […] This approach has some grains of truth to it, but it goes wrong when it leads people to place excessive attention on strengthening or activating one or two postural muscles like the multifidus or transversus abdominis, while neglecting the rest of the […]

  20. […] Yet more evidence that pain lives in the brain not the body. […]

  21. […] temporarily pain free after suffering very severe injuries in an emergency situation. Many people without back pain show herniated discs or other spinal abnormalities on MRIs. These results help prove that physical harm is neither […]

  22. Mri Scan is clinically FALSE -75 % useless,surgeries are 100% ineffective ,chirop/Ostep.etc uselerss ,especially in chronic conditions .Dr Sarno is spinal layman = idiot !

  23. […] of this blog is that therapies attempting to treat chronic pain should target the brain for change, not just the body. Some recent studies based around sensory tricks or illusions provide further compelling evidence […]

  24. NO DOCTOR NO MASSAGES NO CHIROPRACTOR NO
    SHOT’S INJECTIONS SURGERY’S ETC ETC IS GOING TO FIX YOUR BACK ENOUGH IS ENOUGH ONE’S YOUR BACK GO’S YOUR SCREWED FOR LIFE, DEPRESSION ANXIETY AND BEING MISERABLE FOR LIFE THAT’S IT YOUR DONE GET USE TO IT EVEN THOU IT’S HARD TAKES A TOLL ON YOUR LIFE THAT’S THE WAY IT IS FOR ME FOR 13 FREAKEN YEARS.

  25. browneyezblue says:

    “Leg length inequality seems to have no effect on back pain unless it is more than 200 mm (the average leg length difference is 5.2 mm). ”
    200 mm represents nearly 8 inches. Could this be a error perhaps?

  26. holly says:

    wow, well, as a person with ehlers danlos syndrome, i can say that absolutely core strength and posture effect my pain levels! ask anyone suffering from a rsi/upper cross syndrome if their posture is important! this is where studies imho are quite worthless.

  27. Mike says:

    Tod I totally agree with your article above and the debunking of some of the mainstream myths about pain but can you give me your thoughts on chronic pain associated with chronic tendinosis. Is this pain “all in the head” or is there a “physical” basis?

    • Todd Hargrove says:

      Mike,

      Excellent question. The idea that pain is in the brain shouldn’t be confused with the idea that it is “all in your head.” Tendinosis is a very real pathology of the tissue that is likely to cause nociception and pain. The amount of pain is up to the brain of course, but treatment should be directed at healing the tissue as well as any exaggerated response by the CNS. Paul Ingraham has some excellent articles on tendinois at his site saveyourself.ca. For example …http://saveyourself.ca/articles/repetitive-strain-injuries.php

  28. Mike says:

    Curiouser and curiouser.

    Thanks Tod, I almost totally agree with Paul. Tendionosis and the associated muscle strain are extremely under-recognised and yet one of the most common pathologys on the planet. If they are diagnosed, they are often completely mistreated and mismanaged and the problem continues. Whats going on?

  29. john power says:

    “Core training” was initially developed as a muscle activation/reeducation program intended for people with low back pain due to segmental spinal injury and joint instability. Research has found local stabilizer muscle inhibition due to joint injury – this happens to be true with all the joints of the body. Excessive joint movement/translation is a common finding in people with joint pain/degeneration, poor movement control and decreased proprioception. Local joint stabilization via muscle reactivation and cognitive movement reeducation is the bigger picture of a comprehensive spinal rehab program. Core training through the fitness field has become something different. There are many reasons why someone may have back pain. The application of any intervention is only successful if the treatment meets the injury/symptom etc. My complaint is that studies are about numbers and statistics and not about individuals.

    • Todd Hargrove says:

      John,

      You make some good points about the fact that “core training” is a general vague term to describe some very different approaches.

      But I’m not sure I agree that studies can’t be used to judge the efficacy of any particular form of core training, just because different individuals will respond differently to it.

  30. MRI studies in the low back show fatty deposits and atrophy in the lumbar multifidi. To correct the long standing atrophy observed in the lumbar multifidus, patients must engage in strengthening exercises targeting the lumbar extensors. And should begin incorporating an isometric “pause” into these exercises. This model has been shown to correct the multifidus atrophy seen in the experimental population.

    • Todd Hargrove says:

      Dr. Reza,

      Do you know of any well controlled studies which show that multifidi strengthening exercises improve low back pain better than general exercise? My guess is no, but if you can prove me wrong I would love to see them.

      • Rob says:

        Reasoning flaw alert:

        1) Pain inhibits multifidis and alters motor recruitment.
        2) Multifidis is shown to be atrophied in specific (painful) segments, and motor recruitment patterns are changed.
        3 Ergo: Strengthening multfidis and normalising motor control will result in pain relief.

        Marks = 1)correct. 2)= correct 3)incorrect.

  31. Brad says:

    Hi Todd ! Great article ! I am a PT, but also suffering of back pain…. You are right saying that MRI abnormalities are not predictives of back pain and I share totally your opinion about core training. Some rugby players have back pain and some fragile women that never did any strenght exercises in their life haven’t, so it is not in the pure strenght. In my case my first back pain acute episode were when doing some flexion in the early morning, lifting something heavy after swimming during 1H30, or straighten after bending with a twisted movement, or even lifting something after stretching. In all this episode there is the same pattern : a bending twisting movement when ligaments and muscles are too relaxed due to an extended position.
    The problem is when we reject strenght, core or MRI abnormalities, what is left to explain why people hurt themselves and suffer while others don’t? Motor recrutment pattern? But here again if it is the case sportmen should have less back pain because their recrutment pattern is supposed to be better than the average person…
    Let me know your opinion about that !

    • Todd Hargrove says:

      Thanks Brad. I don’t mean to suggest that a disc can’t cause pain, only that a disc abnormality is not as good a predictor of pain as we are often led to believe. In your case, it sounds like a disc may be contributing to your back pain. Maybe motor control could help with that. Or maybe not!

      If motor control is a big factor for back pain, then yes athletes should have less back pain for given levels of mechanical stress. But athletes are under more stress of course. And, it may be that the motor control patterns that help control back pain are different from those involved in sport.

  32. bon says:

    The more realistic information I find regarding back sufferers is that we are beyond human aid. While drug addicts celebrate birthdays and receive chips for no longer stealing, lying, cheating and thieving others for medications that don’t belong to them the rest of us are just told to “suffer”. I have a severe curvature of the spine and strengthening my core would simulate muscles of a hulk. It’s not a reality. Every bit does help, but there’s not much more I can do with eight bulging discs and the pain is still pervasive. Don’t be confused. I’m in pain right now. No one should suffer this much.

  33. Christian Currie Rabhansl says:

    Posture, 1 paragraph: The picture you draw here is the picture of statically holding the body in contrast to what Feldenkrais recommends which is actor instead of posture. Acture = fluid, dynamic.

    I like this post. Checking out the meso-, and ectoderm soon.

  34. Great post Todd. As a Rolfer down in Austin, TX I am constantly looking for ways to get better at our craft and your posts always incite my imagination. Thanks!

  35. Alex Birger says:

    Todd,
    I enjoyed reading your posts, they are a great resource. I am in health care myself, in a pain related field so many concepts are very familiar.
    I am experiencing a very difficult and puzzling situation personally. Formerly a college track athlete, I have always been very active and fit. Some back pain 2 yrs ago prompted an xray – it read spondylolisthesis L5-S1, of unstable type. I continued to feel occasional flairups of back pain but overall remained quite active and functional. Last year was a very trying year for me emotionally, and I think my CNS experienced a serious shake-up. Concurrently, in Dec 12 I began to have a severe flair-up of my back with pain and numbness down both legs (MRI – bulging disk at that level, consistent with my symptoms), as a result I am able to do very little (but still working through pain) and nothing so far has helped. Massage, chiro, PT, core-work, mental stuff – slight, brief or no improvement at all. My surgeon (smart, conservative and a friend) says I need a discectomy and a fusion to get better. I am slightly hesitant to do it, still hoping my body or mind will take over, and finally make it go away. Or there some non-medical, magical way. But nothing has helped and my level of disability is high. I am 40, too young to spend rest of my life like this. One puzzling feature of this situation is the fact that I sustained a very nasty physical problem right after a year of very bad emotional issues…. What is your opinion?

  36. Majed says:

    Thanks a lot.

    Your article completely destroyed my plans for core exercises.

  37. mj says:

    Problem he is it is simple deconstruction for the sake of it.

    There is no constructive alternative. The same brush that classic medicine uses to tar complimentary for being pseudoscientific clap-trap is now used by complimentary medicine to tar other complimentary medicine view points or even itself.

    To problem with this article is the following:

    To say that a posture that is more arched in a teenager than an aesthetic norm causes no problems is almost moot.

    The body will develop itself to a degree of equilibrium and can take many variations to reach it. You cannot compare the mechanics from a purely aesthetic point of view.

    Although the arch may be increased in one teenager is only looking at one aspect, it is failing to see if that same teenager has also developed other physical aspects to makes this posture an advantage, or at the least be compensated for this change.

    In a nutshell.

    Bad posture is RELATIVE to the person, not an norm defined by aesthetics.

    So take the same high arched person and ask them to decrease it, may cause back pain in the same way increasing the arch of those with an aesthetically pleasing one have will also cause pain.

    So the conclusion reached is not always the one expected.

    A more constructive approach is to look at how the body failing to adapt to its environment within the development of its genetic norm is better. Looking AT the person, rather than trying to fit people into mechanical norms of a population is a problem of classical medicine.

    As example, do we all REALLY need to be 120/80 in blood pressure?

    Really? Whtever age, sex, height?

    Obviously it cannot be, this number is the best compromise in the same way brisbane is the best capital of Australia.

    So learning to understand the person from THEIR perspective and compensation in a contextual approach is better, allow us to develop methods to treat that.

    But this of course is a lot harder to use classic scientific method as it makes it all terribly subjective. Which ultimately is the problem, people ARE subjective..

    Anyhow, my two cents

    Martin

  38. Prakash says:

    Todd,
    Can you cite the studies or link that you were referring to?
    “…In one study, researchers looked at the posture of teenagers and then tracked who developed back pain in adulthood….Another study looked at increases in low back curve and pelvic angle due to pregnancy…”

  39. Ray says:

    This article might have been interesting if we had any idea of the validity of the research quoted. As a research scientist with 40 years of experience and many published articles, I know that the majority of research is either statistically invalid (two few random subjects), or uses flawed methodology (or both). This is one of the major reasons research results contradict each other frequently, and why people become frustrated with conflicting advice.

    • Todd Hargrove says:

      Ray,

      Your comment is so general and vague that I’m not even sure whether it is spam generated by a robot. It could be posted on almost any article discussing research and have just as much relevance. If you have any specific objections that would improve our understanding of this subject, I’m all ears.

  40. Dr. Gordon says:

    I have to say it looks like the pendulum has swung a little too far in the other direction. There is some truth to what you are saying and I know you are trying to make a point by attacking some held beliefs (with some specious arguments) but if you’re going to do that come correct with sources. Thanks for throwing stones, it’s important to questions our beliefs.

    • Todd Hargrove says:

      Dr. Gordon,

      Everyone has a different pendulum, and there are probably at least a few prax who have swung theirs too far away from concerns with MRIS, posture and core strength. But IMO the great majority are still too far attached to these ideas.

      As to your accusations that my arguments are specious and my sources are incorrect, please provide some detail. I find it telling that you have provided absolutely no specifics to support your claims.

  41. Matt says:

    Todd,

    From reading the abstracts of the studies you cited regarding poor posture being unrelated to pain:

    1) An epidemiologic study of the relationship between postural asymmetry in the teen years and subsequent back and neck pain – This study seems to be examining the hypothesis that poor posture in teen years may be predictive of subsequent back pain, and it shows that it is not. But that does not prove poor posture is not in some way correlated to back pain.

    2) An analysis of posture and back pain in the first and third trimesters of pregnancy – I don’t think a sample size of 12 pregnant women is really a large enough sample size to generalize off to population at large. There are a lot of “confounding factors” going on during pregnancy! Are there other studies that would be more applicable to the population at large?

    3) Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health – The abstract says: “The included studies were generally of low methodological quality.” The conclusion seems to simply state that given the poor studies at this point, there isn’t evidence to say that they’re related, but the studies have been of low quality and better studies may change the conclusion. From the conclusion: “Evidence from epidemiological studies does not support an association between sagittal spinal curves and health including spinal pain (the claim you’re making). Further research of better methodological quality may affect this conclusion, and causal effects cannot be determined in a systematic review.”

    That said, I don’t think exact spinal curvature angles will ever be shown to be a reliable predictor of back pain (individual variance in tolerance would be too confounding). The example I think of is that two very fit and strong olympic lifters may be able to c+j 200KG with no problem/no pain/no issues but their lower back curvatures will not necessarily be the same.

    4) Tightness of hamstring- and psoas major muscles. A prospective study of back pain in young men during their military service – I don’t think you could ever blame one (or two) muscles for all cases of back pain. This seems like they’re certainly barking up the wrong tree and kudos for sharing this.

    I think in the end back pain has too many possible causes and individual human beings have too many complex intraorganism interactions to chalk up nondescript “back pain” to just one or two culprits with any generalizable reliability.

    I’m a fairly firm believer that posture can be one of the factors in back pain episodes — meaning that there is a right way to use the spine when sitting, standing, and moving. I find it hard to believe otherwise but am definitely interested in knowing what holes can be punched in my belief. Would you say that how you position your spine doesn’t matter in a 300 lb. deadlift? Or a 600 lb. deadlift?

    • Todd Hargrove says:

      Hi Matt,

      Thanks for the detailed response. I also find it hard to believe that posture is not better correlated with pain in these studies, and I would love to have someone show me why these are wrong. Here are some specific responses to the points you made.

      I think you are right that there are some weaknesses in some of the individual studies. But to me, the studies on a whole have a clear pattern – that is it is pretty hard to find a correlation between back pain and almost any measure of posture in almost any population. The meta-analysis considering I think over 40 studies comes to the same conclusion.

      I certainly think that how you position your spine during the heavy deadlift matters, but I see this is a very different issue. We are talking about posture in the context of the activities of everyday life, not posture in regard to one highly specifically stressful event. I think Stu McGill’s work goes a long way toward showing that the orientation of the back during heavy loading matters. But that doesn’t mean that the degree of spinal curvature that we use all day long predicts chronic pain.

      I do have two major questions with these studies. First is whether people accurately report their pain. It seems possible to me that people with a lot of pain will understate it, and people with very little pain might overstate. For example, If you asked my mom and my seven-year-old daughter how much they have pain they have in a week you might get similar answers, even though I know that mom is hurting way more. So if people tend to habituate and normalize their level of pain this would tend to compress the data.

      Second, I’m not sure how well these studies control for function. In other words, even if two people have the same level of back pain, one might be out there running 30 miles a week while the other is sitting around doing nothing, because they know that any sort of activity would make them hurt. Perhaps we all gravitate towards some acceptable pain level, and function is the more important variable.

      Maybe the studies actually answer these questions but I don’t really know. If anyone does have answers I be very interested to hear from them!

  42. Matt says:

    Forgot to check back for a response!

    Is the meta analysis you’re talking about the one referenced above that said the studies examined were all of low methodological quality? If we have two people bad at arithmetic tell us that 2+2=5, is conclusion more valid if they have another 38 people tell us the same? I don’t think it makes sense to use the conclusions of a large quantity of questionable data to conclude much of anything. The most I think you can confidently conclude is that it is not THE issue all the time. From my clinical experience, that’s definitely true.

    I don’t see deadlifting and activities of daily life being so different. There are simply scaled versions of functional activities that provide a varying degree of challenge depending on the individual. A frail, 97 year old woman with low bone density and zero hip strength&mobility will respond to picking up a 10 lb. bag of groceries much differently than a 22 year old wide receiver — even if both do it with poor form/posture.

    I think static posture is just one test of function. If you can’t achieve remotely neutral spinal/hip/shoulder position when simply standing around, every other activity from that position or from a more complex one is likely to be done poorly. I think that dovetails quite neatly with your second question about whether people simply scale back their activities. How many times do we hear “I used to [run, hike, wrestle, do jiu jitsu, rock climb, bike, etc], but I’m just too old* for that now.”

    *old turning out to mean “my [back, knee, hip, shins, feet, shoulders, etc.] bother me for days or weeks every time I try.

    • Todd Hargrove says:

      Hi Matt,

      Those are good points, thanks for sharing.

      I’m not sure about the effect of the poor methodological quality of the studies in the meta-analysis. Garbage in garbage out for sure, but it seems to me unlikely that the methodological problems with each study would somehow bias them in favor of finding no correlation between posture and pain. Perhaps if the studies had been done better, correlations would have been more apparent. But then this just creates one more hurdle to jump over to believe that posture and pain are correlated.

  43. aaron says:

    I am a structural integration massage therapist who is a big fan of Lorimer Moseley’s work (ie: don’t believe pain is solely in the tissue) And also believe that structure alone is not a predictor of pain, but I get fantastic results with my clients by treating their pain as a functional/structural/inflammatory issue.

    I don’t spend time or believe it is necessary to “change” what I see as postural deficits, but I do find that these are wonderful predictors of where we will find chronically inflamed trigger points and upon treating those trigger points (ie:increasing blood flow and releasing hypertonicity) most clients experience not only reduced pain, but both subjectively and objectively the type of spontaneous erect posture (without any coaching) that is often discussed as the ideal.

    I have written comments in online forums before and encountered much skepticism (which I appreciate) of the theory that functional/movement imbalances are irritating to chronically inflamed myofacsial trigger points, and thus informing peoples experience of pain, and yet over and over again I am getting incredible results (with low back pain very near 100% of clients report significant reduction in pain in their first one hour session, though more certainly within three or four sessions roughly two to three days apart).

    My clients often remark that they have been treating with chiropractic, massage, physical therapy (though most often in a non-coordinated manner) with little result and want to know 1) why I was able when others were not to contact the points which felt familiar to their experience of the pain, and 2) why none of the other treatments had been successful.

    I am adamant that this is not some “special touch” that only I possess or am capable of performing. I was taught these protocols as a part of my training, and yes they are exacting, repeatable protocols, with some variation being inevitable due to body type, sensitivity to pressure etc.

    I would love to be working in conjunction with scientists interested in disproving the type of structural/functional/inflammatory theories I have been utilizing in order to get to the bottom of why my anecdotal success rate is so near 100% on the very first try.

    Finally, while I realize my statements could seem braggardly I would like to emphasize again that these are repeatable protocols which were passed on to me by mentors, and which I feel could be taught to anyone interested in learning them, and I myself would love to know more about why they are effective even if it means disproving the structural explanation I was given in my education.

    I have really enjoyed the content you provide. Thank you for producing such great website

    • Todd Hargrove says:

      Hi Aaron,

      Thanks for the comment and congrats on your success. You don’t sound like you are bragging to me but I do admit I’m skeptical. If you really are achieving such great success by a protocol which is repeatable and teachable to others, you should really consider trying to make this method better known and have it scientifically validated. If you are correct in your claims and could have them proven, this would truly be one of the great medical breakthroughs of the century. Best of luck.

  44. aaron says:

    I am working on connecting with researchers regarding this work, but I would postulate that there are better positioned minds/practitioners than me already doing so.

    These techniques/protocols come straight from luminaries in the structural integration community such as Vladimir Janda, Ida Rolf and Feldinkrais, and students from their direct lineage, Tom Meyers, Erik Dalton, Art Riggs. All of these people have far greater experience, education and position, and as well I believe, are involved in advancing the research.

    As much as I would like to say that it is my unique touch or system of application which is providing these results, these are well publicized philosophies and protocols and I would hardly have any insight to offer except than I am one more practitioner having success providing my clients pain relief with them.

    I appreciate your adherence to sticking with what is known in the current research, and believe that most of the above stated luminaries would agree, but I am forced to wonder at how we are all getting such repeatable results across a broad spectrum of clients and practitioners utilizing structural hypotheses if the structural component is indeed not at play.

    As someone who prides himself on looking for verifiable scientific evidence in all facets of life, when we find ourselves looking at such large, dynamic, and organic, and social systems, where isolation and double blinding might just be impossible, could there be a system of analysis of the anecdotal evidence which would provide satisfactory evidence for implementation of said hypotheses in the mainstream? Not to say that they would be above scrutiny, again I myself would love to continue the search for the underlying processes, but we could say that they have reached the level of an “almost theory”. That they are repeatable enough to accept they are not misguided, but that we just aren’t certain yet how they function, similar to quantum mechanics in computing.

    I suppose that this is somewhat how things are progressing in the field of bodywork, what with being accepted occasionally by insurance panels, and eking toward mainstream medical interest in our results, but the fact that you and others continue to be skeptical of claims such as in my earlier comment, and that the studies which you sight seem to be so far removed from the way structural work is applied in the field as to seem as though they are unaware of the philosophies of the greatest minds in the field, makes me wonder if we will ever be able to achieve gold standard evidence, and this is in fact the reason why I have chosen to continue my path as a practitioner of embracing structural hypotheses while presenting clearly to my clients that these are not “known“ entities.

  45. aaron says:

    I have noticed that my name is not posting at the top of my two comments so far. I hope that is not confusing as I did not intend to post anonymously.

    Aaron Allen LMT

  46. aaron says:

    I am also curious of how you and other practitioners in this forum discuss your treatment strategies with your clients regarding lack of evidence.

    I know that I will often qualify statements when asked by explaining that we are not entirely sure how “abc” technique is working, though the results do speak to “xyz” possibilities, but I worry that lay persons will latch on to talking points too much as gospel when they fit their preconceived notions.

    I’m sure we have all experienced the client who walks in to our practice and has been informed they “have” such and such a condition because another (many times unqualified) practitioner told them so, and how hard it can be, the fine line between correcting that point of view and instilling yet another misguided belief.

    Its obvious that you have chosen to continue as a Feldenkrais practitioner and others their own methodology, but as an open ended question, how do others deal with explaining why we have chosen a particular course of treatment/action, or how a particular result was achieved, or why the work has been effective, when we seem to be in agreement that the jury is still out?

    Aaron Allen LMT

  47. I am a Physio, too & since I discovered the Feldenkrais Method & became a practitioner 20 years ago have used it almost excusively because it deals with our habits, which are always at the root of problems.You can have PT, Chiro, massage etc. which all help a little, but you walk out the door straight back into your habits, so treatment doesn’t last. The FM gives us many variations of functional movement so we don’t always act in our habitual patterns. When the nervous system begins to notice differences, we can change our habits subconsciously & those new movements will last!These small, slow movements can help to release muscles that are working unnecessarily & relieve ischaemic pain. Joint spaces can open up & take pressure off compressed tissues. people can learn how to relieve their own pain & do all their activities joyfully again.The FM empowers us to be our best selves again.

  48. Klaus Johannsen says:

    Hi Guys,

    you are totally wrong, guys. Of course, it is exactly wrong posture, which is causing back pain. The right exercises will remove any of that problems. The real problem is, that exercise and exercise is not the same. Just strengthening your core will not help you. The body is a complex system and the different parts need to be in balance. That physiotherapists often are not able to help you, does not prove that posture isn’t the cause. It just proved that the therapists have not the necessary skills.

    Guy, look in the right direction!

    C. Klaus

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