Is it bad to bend your back?

correct way to lift (Manual handling).jpg

It’s estimated that 50-80% of us will experience low back pain in our lifetime (Hartvigsen et al. 2018)

Much like the common cold, we may experience episodes of back pain throughout life. Many associate bending/flexing the spine with injury and back pain. In fact, workplace manual handling training encourages lifting to only be done with a neutral or straight spine to reduce the risk of injury (Nolan et al, 2018). However, not only is manual handling training ineffective at reducing back pain and injury (Clemes et al, 2010), but the recommendation to keep the spine straight is not evidence-based and may be unnecessarily harmful. See above for two perspectives on how to lift, the first being manual handling, the second being how to lift a very heavy (atlas) stone. Confused? Us too. Read on.

Although lifting does increase the pressure in the lower back, this is normal. The lower back is a strong and resilient structure that is adaptable (the NOI guys tried to change the word ‘vertebral-disc’ to Living-Adaptable-Force-Transducer, or LAFT, unfortunately, it didn’t catch on!) and therefore loads that we lift can be tolerated by the structures in the back - if graded. A recent systematic review (one of the highest levels of research evidence) demonstrated that having a flexed position of the lower back during lifting was not a risk factor for low back pain development or persistence (Saraceni et al. 2020).

So if these recommendations to avoid bending our backs aren’t supported by research, how did we get here? Some healthcare professionals have misinterpreted research published in the 1960s about the pressure on spinal discs in different positions to mean that these positions should be avoided. The research showed that in spinal flexion, the load on the intervertebral disc was much higher than any other position (Nachemson, 1965).

“If recommendations to avoid bending our backs aren’t supported by research, how did we get here?”

This has led to advice from healthcare professionals that the back cannot tolerate bending and they have passed these beliefs onto their patients thus perpetuating the problem. Many people now believe that the back is a vulnerable structure and this is more likely to lead to a conscious or subconscious protective strategy when moving and lifting. In turn, this can lead to hyper-vigilance and concern that may ultimately predispose someone to develop persistent back pain (Darlow et al. 2015).

Such an ingrained societal belief is difficult to challenge, however in my experience, encouraging individuals with low back pain to flex their spine and load it through its normal range of motion has led to some lightbulb moments – spines are meant to move. Examples I like to use with my clients include that of Sherpas living in mountainous regions.

Local Nepalese porter carrying upward of 100kg up the Himalayas, taken by B2R in 2019.

It’s normal for them to have extremely heavy loads strapped onto their flexed back and neck while trekking up the surrounding mountains. Did they start off with heavy loads? Perhaps not. What likely happened was a concept called graded exposure (read more here). They would start off with a weight they could tolerate, and then gradually increase it as they got used to it. The same goes for strongmen and women who lift atlas stones. In order to get the awkward load off the floor, their spines must flex significantly. But they would of course start at a lower weight stone before increasing it to the heavy ones you see in competitions.

The body will adapt if asked to, even to lower back flexion.

Recent research has demonstrated that lifting with a flexed lumbar spine is more efficient for heavy lifting when compared with lordotic (arched or neutral/straight back) postures (Mawston et al. 2021). Bret Contreras, Ph.D. describes the so-called ‘neutral’ posture as more of a range than a static position (Contreras and Cordoza, 2019). Whilst we will be fighting to maintain a neutral spine through a heavy lift, being aware of the enhanced efficiency of a flexed position might well explain what we see in a maximum effort lift from the floor (YouTube deadlifts!). In the event that we cannot achieve a neutral position for lifting (scroll to the very top image of this page, see the Sherpa or strongwoman above), it is the principle of adaptability we can be grateful we have a spine for.

IMPORTANT NOTE: This is an image by Eugen Loki we have retrieved from page 139 in The Glute Lab by Bret Contreras (2019). The concept of a neutral zone, as described and shown visually is a helpful one. The colour scheme of ‘red’ in end zone could b… — IMPORTANT NOTE: This is an image by Eugen Loki we have retrieved from page 139 in The Glute Lab by Bret Contreras (2019). The concept of a neutral zone, as described and shown visually is a helpful one. The colour scheme of ‘red’ in end zone could be interpreted as ‘danger’ or to avoid. This is not in reference to everyday movements of spinal flexion, it is with maximal high load lifting. This distinction is important and a nuance many professionals and coaches argue over. Our advice; fight to maintain neutral through max lifts, although you may not be able to actually hold neutral, and this is fine, we just don’t want to be spending most of our training here. Under lower loads and everyday movements, absolutely flex your spine as required.

But I’m not a strongman and I don’t live in Nepal?

We don’t have to be Sherpas or strongmen in our everyday lives, however, the principle that the spine should not bend under load simply doesn’t hold up under these examples. The position is not the problem, it’s the load tolerance of the individual with their current physical capabilities that matters. As long as we gradually introduce load to our spine throughout flexion and extension, we will expand our capacity and tolerance and we’ll be much less likely to injure ourselves.

“The position is not the problem”

With the prevalence and persistence of low back pain and its associated disability on the rise (since 1990, back pain has been the number one cause of years lived with disability), perhaps our current treatment models could be improved (Hartvigsen et al. 2018). Principles we used to think essential in the management of back pain such as imaging studies, bed rest, and keeping the spine straight are now outdated and likely to lead to worse outcomes.

What’s the solution?

So what’s the solution? Low back pain is complex, but the treatment of it does not have to be. Some of the best things to consider are listed below.

1) Learn and understand more about back pain.

It’s unlikely a serious condition and it will generally improve with time.

2) Move more

Our spines are designed to flex and extend (that’s why we have so many vertebrae rather than one long rod like our shin bone for example).

3) Fear less

The more we worry about something, the more of a big deal it becomes. I know from personal experience that the more I worry about doing a task, the harder it is to actually do it! Usually, when I get on with the task at hand, it’s nowhere near as scary as I thought. Applying this to moving our backs is important.

4) Graded exposure

The concept of use it or lose it applies here. If you bend your spine regularly within your capacity, it will gradually increase and improve. If you avoid such movements, you’ll likely gradually lose the ability to do them.

Graded exposure. Taken from the B2R self management workbook

5) Pain does not always mean damage

Especially if you’re introducing a new movement, you will likely experience some protective sensitivity or soreness. This is normal! Don’t push things further than your capabilities to start with, but be consistent

Check out the B2R online back pain self-management programme at Results, Wellness & Lifestyle.

6) If you want expert programming on heavy lifting, check out companies like Barbell Medicine or Stronger by Science (just two examples).

How do you lift?

Sam Ogilvie, MChiro, LRCC :)

For further information or to book a consultation in person or via Telehealth, contact Sam Ogilvie via Instagram (@samo_b2r), Facebook (Sam Ogilvie) or email (sam@backtoroots.community)

Contact Sam via Instagram