Our reference,
–Evaluation of factors associated with severe and frequent back pain in high school athletes
We looked at a bunch of potential factors. Which ones correlated to having highly intense and frequent back pain in athletes 14-20 years old?
When we say a bunch of potential factors, we mean a bunch.
Association (χ2) and prevalence ratio of back pain intensity with independent variables
-(demographic, socioeconomic, anthropometric, and psychosocial)
-(exercise level, behavioural, and postural)
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Association (χ2) and prevalence ratio of back pain frequency with independent variables
-(demographic, socioeconomic, anthropometric, and psychosocial)
-(exercise level, behavioural, and postural)
–
After all that, what factors were most associated with intense and frequent back pain? Highlighting factors where the prevalence changed by 10% or more:
Quoting,
“Bivariate analysis revealed an association of back pain intensity with behavioural and postural variables, and back pain frequency with sex, exercise level, and postural variables.
After performing multivariate analysis, only the time spent using a computer and sitting in a posture to write and use a computer remained associated with back pain intensity, and reading or studying in bed and the method of carrying a backpack remained associated with back pain frequency. These behavioural and postural factors were associated with increasing back pain frequency and back pain intensity. Athletes who used a non-recommended sitting posture to write and use computer demonstrated higher prevalence ratios and were more predisposed to greater back pain intensity.”
1. This is a great study to illustrate the importance of the other 23 hours a day. This study was meant to examine athletes, yet found all the non-athletic postures and movements were more relevant than the sport the athlete played!
-Five years ago: Why you’re still in pain
2. Predictably, none of the pain science world evangelists seemed to mention this study. Those championing the hell out of the biopsychosocial model of pain. Because frankly, this study only found bio was relevant. Even for the sleep numbers, which did have some (non-statistically significant) relationship, one has to laugh when you see the authors go,
“Although sleep time was not associated with [back pain], insufficient sleep may impair athletes’ musculoskeletal tissue recovery and make them more tired, contributing to the adoption of inappropriate postures.”
So when biopsychosocial zealots harp on things like sleep quality, who says they aren’t still harping on a bio factor? A posture factor?
-> We are not saying psychological and sociological factors don’t matter. We’re saying considering them as wholly separate from biology is precarious, and for some, the pendulum has swung too far away from biology.
In fact, many talk about lack of sleep, but this study found TOO MUCH sleep was something worth considering too. And even that has a direct biological implication at the spine,
–Exercising in space- when spinal DEcompression is a concern for lower back pain
(Astronauts are renown for lower back pain because they don’t compress their spine in microgravity. The more you lay down / sleep, the less you compress your spine = potential for more back pain.)
It’s no different than harping on those who are depressed being more likely to have lower back pain. Sure, there is always the chicken and the egg issue, but many of us have no problem spotting depressed posture either e.g. hunched over.
It’s pretty damn hard, if not impossible, to parse out depression, or sleep, from the rest of the day.
Meanwhile, this is a solid look at an inordinate amount of biopsychosocial factors and back pain. Going all the way to hand grip strength. It’s not even close how many of the factors are non-psychosocial. If you look at the highlighted numbers, you can see posture related factors overwhelmingly were most predictive.
The “posture doesn’t matter” crowd wants to single out “somebody stands still, looking at a wall” as examining posture. The rest of us aren’t so literal. We understand posture has a more dynamic definition. How you stand when holding your kid vs when using a standing desk, how you sit while typing at a desk, how you sit when relaxing on the couch, how you lay down when reading vs sleeping, how you walk freely vs how you walk when holding a backpack of five overpriced textbooks.
That does matter.
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Learn about the most common posture issues
Exercises to fix common postural problems
Or get specific help assessing and changing your own posture
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Rory
December 14, 2017
Hi Brian, interesting post.
I was really hoping that they actually tested the postures and movements to see how each individual performed them. But I was disappointed to see that all of the posture responses were part of a self-administered questionnaire. I don’t want to be one of those psychosocial zealots, but one could easily make a case for the role of expectation and understanding influencing their responses. Check out the ‘BackPEI’ which is the outcome measure they used. The posture section simply asks the participant which 1 of 5 pictures most accurately represents how they perform each task. A lot of kids probably don’t even think about how they sit or pick things up. And it would make a lot of sense that someone with pain would concede to using the ‘not recommended’ postures simply because they have been told (from parents, teachers, internet etc) that there is a connection between those postures and pain. Likewise, those with no pain may state that they must use the recommended postures if they have no pain, regardless of whether or not they actually do. The problem is that we are ASKING them how they do things AFTER they already have pain, rather than TESTING how they do things, ideally BEFORE they develop pain. Therefore there is almost no causative relationship.
I believe posture can play a role in pain, but I don’t think this study illustrates this well at all.
I would love to hear your thoughts.
Rory
b-reddy
December 15, 2017
Hey Rory,
Agree, but you can think about how you sit when asked about it. If you’re filling out a questionnaire while sitting, you can look at how you’re sitting in that moment to deduce how you probably most often sit. It’s not a big mental leap to realize how you hold a bag, even if you don’t think about it on a regular basis.
An expectation of how they do these movements / various postures and associating pain doesn’t follow. If the expectation came from adults, then the kids would have regular awareness of how they move. We’ve both agreed they’re unlikely to. I’d add few adults think about how they sit or pick things up either. (Especially in a developed country.) That’s a big reason I have clients!
As far as kids getting information on the internet, this study was done in Brazil. While I’ve had clients from there, only about half the population is online. I can’t imagine a great deal of these subjects (teenagers) are reading about posture. My website stats certainly don’t say so.
Plus, even if all the above were true, we still don’t see any relationship with the other factors. We’d have to say these teenagers are purposely associating certain postures and purposely avoiding associating other e.g. psychological variables. If we dispute the latter, then we have to say nothing these researchers looked at is associated with their pain.
I respect the confounding issue of people get berated into their head certain things are bad, and there can be a psychosomatic aspect of pain which arises from that. That this can be most pronounced in heavy internet readers- by far my hardest clients to work with. However, this is overwhelmingly an issue when it comes to “I know my X muscle is tight. I need a certain stretch.” Or “I have X tear, I need surgery.” It is rarely because the person has associated “I sit this way, I use a mouse this way, I lay down this way.” One reason I write about these topics is because I’ve barely seen anyone else address it.
In general, I don’t worry about the cause of a given person’s pain much. To know exactly how someone’s (chronic) pain started is borderline impossible. I focus much more on what’s associated with their pain, and work on modifying those factors.
More specifically to research- this is always the big bugaboo, often mentioned by the pain science crowd, but it’s a matter of perspective. To expect the above is an extremely idealistic view of research. To assume we are going to do all that before someone has pain -who would sign up for the study?- then follow these people for years and years -$$$- objectively monitoring and quantifying their daily movement -how?- hey, it’d be great, but I’m not holding my breath.
Nor do I see some enormous research flaw by looking at people who have issues vs those who don’t. We don’t need a prospective, randomized, double blinded, study to say smoking probably isn’t a good idea. We don’t need some huge amount of smokers to get lung cancer. (Only ~12.5% depending how you want to look at it.) We instead look at those who get issues and see many more of them were smokers. Is that ideal, causative, research? No. It’s quite flawed. But it’s reality, and not futile.
(This is one of the studies which first opened the lid on smoking and cancer. It’s littered with less than ideal science- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2038856/pdf/brmedj03566-0003.pdf .)
If you’re looking for causative research, I’m not sure you’ll find much when it comes to studying humans. This is why we have endless debates on topics like smoking, guns, climate change, concussions. There is always an ability to criticize this research, but context matters. Like what’s the drawback of *not* smoking? What’s the drawback of getting teenagers to hold their backpack on two shoulders rather than one? Because we’re not 100% certain it will cause a problem? We’re not 100% certain of anything! (Not even physics.)
So my rebuttal to this point is what’s the threshold we should take action for a given issue? If you read this study and work with back pain in teenagers, do you say “Alright, let’s address some of these posture factors” or do you say “Research isn’t good enough” and do…what?