There are many myths around lower back pain and some of these relate to what causes and doesn’t cause lower back pain?
In today’s article, we will go through what the evidence tells us can cause back pain and also what doesn’t cause it, despite some information that you may have heard over the years. Now another point to mention is the word ’cause’, as this may be misleading and inaccurate, a better word is probably ‘risk factor’.
Before we get started it is important to note that research looks at large numbers of people and works out averages. On any research study, there will be outliers that go against the consensus average, so although this article is accurate to the average findings in research an individual person may be different.
The purpose here is to dispel some common fears surrounding back pain that may do you more harm than good, so be open-minded about our list and hopefully, it can help you to minimise your risk of developing back pain!
What doesn’t cause lower back pain?
Bending your back
Contrary to popular belief, bending your back generally doesn’t cause lower back pain. In this study by Villumsen et al (2014), they found no relationship between bending of the back and the incidence of lower back pain. To add more myth-busting evidence they actually found that bending more (up to 30 degrees flexion) actually reduced back pain! People will always disagree with this as people commonly describe themselves hurting their back when bending but this could be down to a few other factors.
The first one could be that, if you never bend your back due to the fact that you believe it is bad, then you will have a stiffer back, creating less tolerance in the rounded position, kind of like the use it or lose it effect. This then means when you do bend, and you will, you will possibly overload the back with an unaccustomed position. The other factor is discussed in the “what causes lower back pain” section further down and this is fear, yes fear can cause back pain!
Not lifting with your back straight
We have been led to believe that when you lift you should lift with a straight back as this is stronger and this is less likely to cause back injury, but does it really? In a study done by Arjmand et al (2005), they had people lift in three different ways. They were asked to lift with a back position that was either straight, bent or natural ‘freestyle’. They found that the freestyle technique, which was actually slightly flexed, was optimal when it came to internal spinal loading and it was found that have more optimal active and passive muscle forces. So a very small degree of spinal flexion, which isn’t straight, is stronger and has less spinal loads.
Again, people will, of course, dispute this but the reason is obvious when you think about it! For example, if you perform your deadlift with strict form and a straight back for a decade, gradually building your weight up then you are strong in this straight position. Have you developed any strength in the rounded position? Not really! So if you happen to bend your back in the deadlift, say maxing out, then you would be at greater risk of injury due to exposing your back to a weaker position due to having never trained the flexed position. If you did train the flexed spine for a decade and built the weight up slowly then your back would be very strong in this position too.
A great exercise for this idea is the Jefferson curl:
What I would say, is that most people over emphasis the lumbar arch (lordosis) in lifting and actually take it beyond neutral anyway. My advice is to strive for straight and providing that you are stable through the lift this is best. The spine will flex without you actively trying to, so it is a good idea to strengthen the rounded position as a separate exercise. This idea is not just in weight lifting either, it is even more likely that day in and day out lifting will encounter more tendency to bend the back so the Jefferson curl would train you to cope better with this.
Sitting has been vilified for various reasons but like anything, it’s all about the dose, as anything can be good or bad with too much or too little. So it is not the sitting per see, but the amount of it that you have in your life. The spinal loads in standing, bending and sitting are all different and neither is better nor worse. Interestingly if you slouch in sitting then there is less compressive loading in the spine and this leads to increased disc height and hydration, which are good things but remember that load hasn’t magicked into thin air, it has been moved elsewhere. That is why slouched sitting has higher shearing forces, which are loads across the joints instead of down through them. So sitting is not bad in itself but if you just sat all day every day then this would be an issue but so would anything else done for long periods (Pape et al 2018).
The reason that sitting has been linked so strongly to back pain is that we just simply sit more and sit for longer than ever these days but if you look at a manual worker then you actually find that sitting helps back pain and this is because this is a change to there personal everyday normal (Korshoj et al 2018).
(You can find out more on this study here:)
Posture gets blamed so much, nearly everyone that I see with a bad back will reference it to me but again is this another myth?
Posture is somewhat invented by us and the body is really designed to work in a variety of positions, so there is no real perfect, in fact, people have such a variety of ‘normal’ postures and this doesn’t seem to correlate with back pain.
For example, here is a study that looked at the arch (lordosis) of the lower back and they used an MRI to assess lumbar lordosis in people with and without lower back pain. They found that men have more lordosis than women and women had no differences in their lordosis between back pain sufferers and asymptomatic people. However, men had less lordosis in back pain sufferers but it wasn’t by much and it was considered clinically insignificant (Murrie et al 2003).
In another study, they looked at the pelvic tilt, which is often blamed for causing lower back pain, in this case, they looked at the pelvic tilts of 120 asymptomatic people. They found that 85% of asymptomatic males had an anterior pelvic tilt and 75% of asymptomatic women also did. The supposed ideal posture of the neutral pelvis was found in just 9% of men and 18% of women (Herrington et al 2011).
So this shows you that people with or without pain have variances in the considered perfect posture and there hasn’t been any real link between these postures and lower back pain. The phrase that comes to mind is “You’re best posture is your next posture”, meaning move more!
A weak core
This is another thing that back pain patients will say to me. Lots of exercises get prescribed to improve the ‘core’ but are we doing the right thing? Does a weak or unstable or underactive core cause lower back pain?
Firstly here is a study by Gubler et al (2010), they compared people with chronic low back pain to pain-free individuals and they found no significant differences between each group when it came to core muscle onset timing. This implies that the muscles are functioning and working pretty normally, whether you have back pain or not so this couldn’t really be considered a cause of back pain otherwise we would see a difference between the groups.
Okay so that’s the timing of the core muscles, what about the strength of them?
Well, amazingly when you bend and lift a weight of 15kg the co-contraction of your core only increases by 1.5% of a maximal voluntary contraction!
Now you could say what about heavy lifting, well test this would increase this load but how many people actually hurt their back from innocuous movements with low or no load? A ridiculous amount, I can tell you, so this would not be a weakness problem at all, even common sense tells us this.
In a study by Helewa et al (1999), they studied asymptomatic people who were identified as having weak core muscles. They gave one group back education and the other group were given back education and abdominal strengthening exercises. Thye monitored them for 1 year and found no significant differences between the two groups. So if you have weak core muscles and you strengthen them you don’t lower your risk of back pain.
Now what I would say is that in some cases, but not most, there are sometimes overload reasons for back pain and in this instance, strength would help, but I wouldn’t do ‘core stability’ type exercises, I would target strength with load in the movements that are relevant to the individuals’ requirements.
What causes lower back pain?
Unfortunately, for all of us, the chance of low back pain increases with age. It is especially true from 30 years of age until about 60, more specifically, chronic low back pain was found in 4.2% of people between 24 and 39 years old and 19.6% in those aged between 20 and 59 (Meucci et al 2015). Obviously this makes a lot of sense because as we age our bodies degenerate and although this can happen without pain it would still be true that the risk of pain would rise with the increased structural decline of the body.
We know that our bodies are designed to be active and we also know that modern life is in opposition to this. We are more and more sedentary in our lives so just being more physically active is good for us. In a study by Shiri et al (2017), they found that increased physical activity may reduce the risk of chronic low back pain by 11%–16% and so being less physically active would increase the risk. Basically get out and do more, it doesn’t matter what it is as long as you enjoy it and can consistently stick to it. It’s good for you in many ways that you may already know but it will also reduce the chance of getting lower back pain too!
Since 1998 it has been regarded that lower back pain has a hereditary component, explaining 74% of the variance in adult populations studied to date. They found that if identical twins spent their lives doing different jobs and sports then the differences in their spinal degeneration were very similar and they have even started to identify the actual genes that are factors in back pain too (Battié et al 2004).
Most people would scoff at this but this one is massive and is in all the evidence and N.I.C.E guidelines. Psychology plays a huge role in how we behave, move and it also affects us on a biological level. So stress, depression and fear are major reasons for some people to get low back pain (Chou et al 2007).
Now, this could be due to a psychological correlation or maybe down to a lack of physical activity due to not being at work or it could even a social effect but it has been found the not having a paid job is frequently associated with low back pain (van Oostrom et al 2009).
Now obesity gets blamed for everything these days and maybe this is partly true. For low back pain, this is hotly debated and the reasons are more around the correlation to obesity rather than the obesity itself. For example, if somebody is obese they will likely have low levels of activity, which we know is a cause of back pain, so is it obesity or low activity? Also, lots of people who are obese commonly have some psychological issues such as depression, which, are also risk factors too. This being said, the evidence does show that there is a link between obesity and back pain as shown by this 2018 meta-analysis by Zeng, where they found a definitive increased incidence of lower back pain in obese individuals when compared to people of a healthy weight and obesity is also considered a risk factor by N.I.C.E too.
Smokers were found that have a higher incidence of lower back pain than non-smokers and this was found to be dose dependant with daily smokers being the most likely to suffer from a bad back. The actual amounts were 23.3% in daily smokers and only 15.7% in non-smokers (Alkherayf et al 2009).
Remember we are all very different so these causes of back pain don’t apply to everybody, every time but they will hopefully improve your approach to back pain. For example, I have seen people who are trying to sit bolt upright and this is actually irritating their back pain but they hold onto the belief that it is best for them when it may be fine to slouch occasionally and this may actually be better. Another example is someone who refuses to bend their back at all due to fear that it will hurt them and this will actually create more problems rather than less. So like I previously said research is great but it cannot tell you your individual reason for your back pain and it is certainly a myriad of reasons all intertwined but hopefully this article has given you some insights into the evidence of what causes and what doesn’t cause back pain and may improve your risk factors for the future.
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