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Lingering problems with sitting
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Lingering problems with sitting - October 11, 2005 5:31:00 PM
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eam
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From: New York, NY 10028
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Hi everyone-
Just interested to see if anybody else goes crazy with this. Lately, I have been noticing patients (mostly lumbar spine/pelvis) who are subjectively and objectively improved and are on the verge of being discharged but have some lingering back pain or SI pain with sitting. Not crazy, but enough that they mention it. It drives me nuts.
Walking is painless, bending over to reach into the dryer is painless, etc etc etc. Whatever aggravating sx's they had, the majority are better. They will come in with A,B,C and D problems and A,B, and C are better but D (sitting) is still achy. But since we live in a "sitting" society, people are going to notice it more and find themselves shifting from side to side to alleviate sx's.
Just curious as to how others deal with this. Assume people have the proper "ergo" setup. That is usually the first thing I will ask.
Maybe this is a germane topic but it seems to be coming up alot lately for me.
Thanks in advance. :)
Erica
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Re: Lingering problems with sitting - October 11, 2005 7:31:00 PM
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FLAOrthoPT
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From: West Palm Beach
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i usually listen and if they say it feels like they are sitting on something, I look closer at SI, pelvic outflares, etc...typically a MET aimed at pulling SI anterior using piriformis, or correcting outflare helps..Or wedge to encourage neutral lumbar spine..
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Re: Lingering problems with sitting - October 12, 2005 1:26:00 PM
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srcase
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From: Michigan
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Erica,
I haven't specifically noticed that outcome, but a couple thoughts come to mind. Sitting is sustained lumbar flexion for most people, which differs from bending over in length of time (tissue tolerance issue) and compression on the spinal structures. McKenzie theorized that prolonged flexion promotes a "creep" effect on the lumbar discs or surrounding ligaments which eventually reach a certian threshold and "cause" pain.
You stated that ergonomics are the first thing you check...are you encouraging people to sit with "perfect" posture to the point where they are trying to sit straight and not move? I would think that the nervous system wouldn't adapt too well to this if already irritated. Try to teach them to dynamically sit and check for activation of trunk muscles to allow for movement/subtle shifting (instead of hanging out on the ligaments or forcing an unnatural posture). I like the Swiss ball for this and Simple Contact to the head and trunk while sitting works great too!
Sarah
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Re: Lingering problems with sitting - October 12, 2005 1:57:00 PM
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jma
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From: NY
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They may have the proper ergo set up but does their body deviate from the positions that we want them to assume? If they stay in one positon for a while and the muscles can't maintain it, then they go back to old habits and perhaps the same old aches again. But they need to be dynamic as well, not just the proper posture to stay that way for hours end. They have to move as well.
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Re: Lingering problems with sitting - October 12, 2005 5:05:00 PM
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eam
Posts: 290
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From: New York, NY 10028
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Ben, Sarah and JMA-
Thanks for the replies. Ben, I usually do the check in standing and then sitting (sacrum, inflares etc) and if I find something I will treat it out. The wedge is a thought. But, I believe there may be something more. Sarah and JMA-I think sitting with a "perfect" posture is unrealistic and generally encourage movement, changing positions etc. The Swiss ball is a nice idea-use it but not as often as I should. Interestingly, the people who complain about this sitting achiness are usually the ones who never exercised a day in their life before they came to PT. I have yet to take the Simple Contact course but hopefully next year if it comes to NY. JMA-agree with your thoughts totally.
I had 3 patients this week who were quite improved and sitting was just the last "holdout" so to speak. I could not figure out the reason why after everything else was better and some of the other positions they were better required sustained flexion.
Erica
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Re: Lingering problems with sitting - October 12, 2005 9:56:00 PM
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Randy Dixon
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I don't have a clear thought on this yet, but it seems to fit into something I've been thinking about. Stability and mobility and determining which is the problem by following the kinetic chain. My initial though, with 3 seconds contemplation is, if a person is sitting and there is a hypomobility in the chain then it has nowhere to express itself except in the back. If a person is standing it can be taken out through the hip and other joints.
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Re: Lingering problems with sitting - October 13, 2005 2:03:00 AM
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Barrett
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eam,
Again, you're making a correlation between fitness and the tendency to hurt while seated. None has ever been demonstrated. I always ask my classes about their sitting tolerance prior to discomfort that will only be completely relieved by standing up. At least 30% hurt after about 15 minutes and they are across the board as far as fitness goes. Of course, I talk way beyond 15 minutes at a time and still they sit as if tied down.
What's the origin of this pain? Is it something other than mechanical deformation beyond their tolerance? How does instability produce that? While seated, isn't the nervous system stressed in a particular way that is reversed by simply standing? Think there might be a clue there? How do you help the patient gain length in that tissue? Is stretching a good idea? How is hypomobility "taken out through the hip"? I've never heard of this before.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Lingering problems with sitting - October 13, 2005 2:28:00 AM
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avalon
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Hi All,
Here is some mechanical explanations.
Eur Spine J. 2005 Apr;14(3):234-42. Epub 2004 May 27.
Anterior thoracic posture increases thoracolumbar disc loading.
Harrison DE, Colloca CJ, Harrison DD, Janik TJ, Haas JW, Keller TS.
Ruby Mountain Chiropractic Center, 123 Second Street, Elko, NV, 89801, USA. cbpdcs@idealspine.com
In the absence of external forces, the largest contributor to intervertebral disc (IVD) loads and stresses is trunk muscular activity. The relationship between trunk posture, spine geometry, extensor muscle activity, and the loads and stresses acting on the IVD is not well understood. The objective of this study was to characterize changes in thoracolumbar disc loads and extensor muscle forces following anterior translation of the thoracic spine in the upright posture. Vertebral body geometries (C2 to S1) and the location of the femoral head and acetabulum centroids were obtained by digitizing lateral, full-spine radiographs of 13 men and five women volunteers without previous history of back pain. Two standing, lateral, full-spine radiographic views were obtained for each subject: a neutral-posture lateral radiograph and a radiograph during anterior translation of the thorax relative to the pelvis (while keeping T1 aligned over T12). Extensor muscle loads, and compression and shear stresses acting on the IVDs, were calculated for each posture using a previously validated biomechanical model. Comparing vertebral centroids for the neutral posture to the anterior posture, subjects were able to anterior translate +101.5 mm+/-33.0 mm (C7-hip axis), +81.5 mm+/-39.2 mm (C7-S1) (vertebral centroid of C7 compared with a vertical line through the vertebral centroid of S1), and +58.9 mm+/-19.1 mm (T12-S1). In the anterior translated posture, disc loads and stresses were significantly increased for all levels below T9. Increases in IVD compressive loads and shear loads, and the corresponding stresses, were most marked at the L5-S1 level and L3-L4 level, respectively. The extensor muscle loads required to maintain static equilibrium in the upright posture increased from 147.2 N (mean, neutral posture) to 667.1 N (mean, translated posture) at L5-S1. Compressive loads on the anterior and posterior L5-S1 disc nearly doubled in the anterior translated posture. Anterior translation of the thorax resulted in significantly increased loads and stresses acting on the thoracolumbar spine. This posture is common in lumbar spinal disorders and could contribute to lumbar disc pathologies, progression of L5-S1 spondylolisthesis deformities, and poor outcomes after lumbar spine surgery. In conclusion, anterior trunk translation in the standing subject increases extensor muscle activity and loads and stresses acting on the intervertebral disc in the lower thoracic and lumbar regions.
Publication Types:
* Historical Article
PMID: 15168237 [PubMed - indexed for MEDLINE]
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Re: Lingering problems with sitting - October 13, 2005 2:33:00 AM
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nari
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Just a thought - static 'proper' posture can be fairly stressful over a period of time, just as slumping in a chair can be.
Might help if you can find in each of these folk (everyone's comfortable posture is different) a neutral, calm sort of position, somewhere between erect and floppy. But whatever the posture, the brain does not tolerate lack of movement for long periods of consciousness. Maybe that is related also to a drop in attention span after 15-20 minutes.
A Swiss ball is comfortable and useful; but here the ergonomic gurus ban them in many places, 'in case people fall off them' which is the daftest thing I have heard yet....
Nari
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Re: Lingering problems with sitting - October 13, 2005 2:45:00 AM
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Jon Newman
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Perhaps sitting still, like running fast, is something someone must practice if they are to do this effortlessly.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Lingering problems with sitting - October 13, 2005 6:42:00 AM
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Geert Jeuring
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From: Möhnesee, Germany
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Hello EAM, are the sx´s when sitting acting up right away or do they need to sit longer. In last case you probably have instability problems due to postural-dehydration. This is a normal phenomenon which should get better with better trained postural muscles, more breaks from sitting. In my experience it is mostly enough to heigthen their general fitness.
Greetings
geert
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Re: Lingering problems with sitting - October 13, 2005 6:43:00 AM
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Geert Jeuring
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From: Möhnesee, Germany
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Hello EAM, are the sx´s when sitting acting up right away or do they need to sit longer. In last case you probably have instability problems due to postural-dehydration. This is a normal phenomenon which should get better with better trained postural muscles, more breaks from sitting. In my experience it is mostly enough to heigthen their general fitness.
Greetings
geert
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Re: Lingering problems with sitting - October 13, 2005 6:43:00 AM
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Geert Jeuring
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From: Möhnesee, Germany
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Hello EAM, are the sx´s when sitting acting up right away or do they need to sit longer. In last case you probably have instability problems due to postural-dehydration. This is a normal phenomenon which should get better with better trained postural muscles, more breaks from sitting. In my experience it is mostly enough to heigthen their general fitness.
Greetings
geert
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Re: Lingering problems with sitting - October 13, 2005 2:05:00 PM
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ginger
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From: Melbourne Victoria
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Hi all , interesting subject sitting, one we all become familiar with to varying degrees depending on our client populations. Mine is a largely inner city population, where the majority have office lives and sporting lives that are seperate. A lot of fairly fit people, though a common feature is long periods of attachment to computers in sitting postures.
Reflecting on some of your comments, I wonder if I might weigh in with a theoretical model and then cast light on the solutions I have found work well . A long time ago I was taught that a sitting posture should be rather straight, with back straight and hip knee flexion of 90 degrees, head held midline with chin tucked and lumbar spine held in. Chair height set to allow elbows to sit in a neutral position at about 90 degrees also. This and other " ergonomic" solutions to sitting related postural demands I've found to be an unmittigated disaster for most. Some were even taught to put their feet up on foot rests to increase the hip knee flexion. These people certainly didn't gain benefit from these lessons and I shudder to remember when I was involved in these demonstrations as a young graduate.
Spines are curved , with force couples integrated to permit force dissipation of various axes and multiple loads. Muscles are grouped to provide support and will do so when the load demands. These same muscles will relax when the load can be said to be carried by ligamentous connections between spinal bodies ,made possible by these dynamic curves. The most important of which is the lumbar curve. It is seen then that when lumbar curvature is lost , increased activity of paralumbar muscles occurs to sustain the load. Maintenace of a lumbar curve has value as it requires less muscle activity to realise stability. ( I'm fond of Randy's "kinetic chain " terms here). To be sure of INCREASED muscle activity in sitting then, just allow the lumbar curve to drop away, as in a knees high posture. To reverse this provide a seat that allows for the knees to be below the level of the hips, as in a swiss ball , or the ergo chair with knee rests that was popular a while back. Or better still sit in a standard office chair with the feet tucked under the chair so that a rolling forward of the pelvis allows the lumbar curve to be maintained without effort. In this way muscle activity is decrased and potential for fatigue related protective activity is reduced. Thus a sitting posture can be held longer without the fatigue /hypomobility/inflammatory event of joints cycle being initiated. It will be noticed of course that as soon as the knees go down and the pelvis rolls forward, lumbar curve is exagerated and other curves normalised , as per standing posture.
I see my "protective response "theoretical model coming into its own here, as reduced threat, can be seen to occur as reduced fatigues associated with postural muscle fatigues reduces.
As mentioned in most posts movements are vital, changing postures frequently is necessary to allow disengagement of specific postural muscle loads. For this reason I find the "knee chair" is unviable, as it is less capable of allowing alternate positions in a way that a standard office chair can .I've noticed a trend away from the swiss ball by users, not because they fall off ( maybe that insurance co was worried they would be doing a balancing act with juggling and plate spinning as well Nari), but because they have to chase them round the room before sitting on the bloody things.
Anyone in a area with folks riding to work on horses?, they ought to have the best chair of all if they could carry on working while in the saddle.
Cheers
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Lingering problems with sitting - October 13, 2005 2:25:00 PM
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nari
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jon
I agree with you - it does require practise to feel effortless while sitting!
ginger, I agree with you too(now how's that?) and the posture adopted for the saddle is close to ideal movement while sitting. Excellent for spinal neural massage...and a good point on the Swiss ball - they do have a tendency to wander and possibly cause litigious accidents for those who try to shove them away with a foot and fall over... :rolleyes:
Maybe someone could develop a pseudohorse machine (not a rocking horse style)that imitates the movement of a horse at moderate walking speed; residual low back pain might disappear overnight...
Does anyone want a challenge? Develop a prototype?
Nari
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Re: Lingering problems with sitting - October 13, 2005 6:39:00 PM
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eam
Posts: 290
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From: New York, NY 10028
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Hi everyone-
Thanks for all the replies. As I am typing here I find myself sitting up to maintain my lumbar curve. And have moved my position twice within 5 mins.
Jon-it is interesting how one thinks that if we "fix" all the mechanical, nervous system, soft tissue problems that sitting will be "fixed" also. I never looked at sitting as an "activity" that had to be practiced b/c I guess I never really thought of it as an activity, so to speak. But I guess it speaks to the specificity of training concept that sitting is a learned task just like walking or running.
Barrett-I wasn't implying correlation between fitness and injury while sitting b/c I have a decent fitness level :) and had my share of problems in a sitting career previously. I thought it interesting from a pain perspective that people will still mention sitting after they have made such good progress with other activities that previously were very painful.
Nari, Geert, Henry and Ginger- It seems that the report from the European Spine Journal and Ginger's theory are somewhat opposite in view. Or maybe I am reading it wrong, b/c it is late here. :) I guess to maintain "effortless" sitting we need decreased mm activity. Which according to the posts above, would be to have a knees low posture. Thus maintaining our natural lumbar curve. But if we are not used to our natural lumbar curve, after awhile wouldn't that translate into fatigue and pain? Or would training the back extensors out of sitting do the trick also? Does that translate into decreased fatigue, effortless sitting and decreased pain? I have rambled on long enough... By the way, the horse prototype is not so far fetched!
Erica
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Re: Lingering problems with sitting - October 13, 2005 8:07:00 PM
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ginger
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From: Melbourne Victoria
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Erica and nari, I have seen a saddle chair being promoted by retailers into the back care and seating market. The price would deter most however, at around $700 AUD, doesn't seem good value when an ordinary office chair with gas lift and saddle tilt will fullfill the clever users needs very well ( at around $70 ).
Now if this chair could come down in price as it should, add some computer aided servos to do a little jiggling movement on command , or perhaps on a timer, and you'd have yourself a winner.
I can sense a market campaign coming on with ten gallon hats and check shirts already.
Yeeeha.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Lingering problems with sitting - October 13, 2005 8:23:00 PM
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avalon
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Erica,
[QUOTE] It seems that the report from the European Spine Journal and Ginger's theory are somewhat opposite in view. Or maybe I am reading it wrong, b/c it is late here.[/QUOTE]I think the paper isn't opposite since it says that immobility is a problem but not motion.
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http://www.somasimple.com
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Re: Lingering problems with sitting - October 13, 2005 9:22:00 PM
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nari
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From: Australia
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ginger..
Good idea. But ten gallon hats?? What happened to Akubra? Check shirts are OK...
I agree the knee chair is not worth its salt, as it locks in the legs and promotes even more immobility.
Erica, I think it would help to practise a sort of 'minimal' sitting - ie using minimal muscle tension - but have not tried it on anyone rigorously. Along with the practice, maybe some diaphragmatic breathing as well...
Nari
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Re: Lingering problems with sitting - October 13, 2005 11:00:00 PM
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Randy Dixon
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Barrett,
I don't see the Erica or anyone else making a correlation between fitness and pain free sitting. What I see is her trying to make a correlation between pain free standing, function and ADL and sitting ones. A correlation which seems reasonable to expect. As far as "taking it out through the hip" of course you have heard of it before, I am talking about compensatory movements. Many manual therapists as you have mentioned before, believe that hypomobility in one spinal segment leads to adjacent hypermobility in adjacent ones. The idea that if movement can't be performed at A then it is performed at B is not new, or controversial. I wasn't talking about specific structures so much though as forces and functions. The hypo/hyper mobility might be the result of neurological, muscular or skeletal problems or "abnormal neurodynamics". When standing all the joints below the level of the spine are available for compensating movement, even subtle movements within the joint. When sitting the hip is stabilized and the rest of the chain below is unavailable, the spine and pelvis also become subject to different gravitational forces as well. This leaves basically only the spine involved. So what was masked becomes unmasked. I wasn't trying to suggest a treatment option, only a possible cause. How one deals with it is variable. I'm sure you would suggest Simple
Contact, Ginger would probably suggest prolonged mobilization, and others manipulation etc.
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