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April 2020 (Vol. 5 Issue 2)

The end of back pain

About the author: 
Katy Bowman

The end of back pain image

In this special issue of WDDTY, we have a trio of articles to help you tackle back pain that results from our modern lifestyles. Biomechanist Katy Bowman offers the best positions for working at a desk, NeuroMovement specialist Anat Baniel provides three exercises to combat sitting (page 32) and our reporter Cate Montana investigates three new therapies that get to the root of the problem: faulty posture

Standing pretty

Now that sitting has been recognized as the latest health hazard, we’re all told to stand at our desks, but biomechanist Katy Bowman has another answer.

hances are you’ve read a headline that screams something like ‘Sitting is the New Smoking!’ These headlines imply that sitting, like smoking, is statistically associated with numerous health issues, including death from cardiovascular disease and cancer, and that it will take some time before we all wise up and quit.

In light of sitting research and ‘sit less’ campaigns, health-minded individuals have been super-motivated to get out of their chairs and onto exercise balls, standing workstations and treadmill desks. The options to sit less are endless, so the notion that standing in one place is the solution to sitting so much reminds me of the joke about all accidents happening 15 miles from your home. “I read that all accidents happen within 15 miles of one’s house, so I moved.” Or “I read that sitting kills, so now I’m afraid to stop standing.”

But sitting itself isn’t really the problem; it’s the repetitive use of a single position that makes us literally become ill in a litany of ways. Your muscles will adapt to repetitive positioning by changing their cellular makeup which, in turn, leads to a reduced joint range of motion. This muscle and joint stiffness can lead to rigidity of the arterial walls within these muscles. The good news is that, because we’ve all been sitting (static) the same way for decades, changing our position (standing more) can improve our health, as can moving intermittently throughout the day.

As a biomechanist, I help people understand that the stance of the body on a gross level (posture) affects the shape of its cells. In other words, the way you’ve been sitting has changed the tiny parts that make up your structure, like the shape and density of your bones, the length of your muscles and tendons, and the resting tension in your connective tissues. This adaptation on a deeper, cellular level to sitting means that reaping the benefits of not sitting so much requires more than just swapping one static position for another—it requires an entire overhaul of the way you think about and move your body.

Indeed, the ‘all you need to do is start standing’ advice made me realize that a more thorough explanation is needed.

In many cases, the physical effects of sitting are just as much created by repetitive geometry (always sitting in the same way) as they are by the metabolic changes that come from being sedentary. So sitting differently can improve your health in the same way that standing can on a cellular level.

But ‘standing’ is not the simple, turnkey solution we think it is. Every way of standing is not equal; some ways will create more positive adaptations.

Heralding standing still as the solution to sitting still perpetuates the problematic belief that we can indulge in a vast amount of stillness—whether sitting or standing—and still have the level of health necessary for a thriving quality of life.

Effects on your arteries

Arteries are arranged specifically to maximize pressure gradients and to keep blood flowing smoothly, but this all changes with posture. Prolonged alterations in arterial geometry
can change the way blood flows, creating scenarios where the loads on the vessel wall induce cellular changes that cause them to shift from atheroprotective (protective against plaque formation) to atherogenic (promoting plaque formation).

In fact, the amount of sitting typically required for office work is associated with increased coronary artery calcification, an early marker of heart-disease risk. One study analyzing heart scans and accelerometer data (how much people move) from more than 2,000 adults found that every hour of sedentary time on average was associated with a 14 percent increase in coronary artery calcification. The association between calcification and sitting was independent of exercise and other traditional heart-disease risk factors.1

For decades, researchers have been trying to figure out the best way to organize the body for optimal performance at the office. The underlying flaw in much of the research—or at least in its presentation—is that it fails to highlight the use of a single position as the problem. Our quest to find an optimal position for stillness will always be frustrated by the problems inherent with a lack of movement.

Fortunately, given our new understanding of the importance of all-day movement as opposed to exercise buried in a mostly sedentary day, a new trend in health research is to look at the physiological and biomechanical effects of sitting behaviors.

This is why the sedentary desk—whether a sitting or standing one—is a problem. If we keep trying to solve the ‘what’s the best way to sit at my computer’ problem, we’ll miss the answer: ‘as little as possible.’

But you still need to work, to sit at your computer and commute with regularity—which can be included in figuring out how to use greater ranges of motion to prevent our muscles and other body tissues from atrophying due to movement deficits.

There are evidence-based ways to sit and stand better, but the conditions that make them better are limited. Which is why, in addition to making postural adjustments to introduce new body loads to work different muscles, you also need to move more throughout the day.

The newest research shows you can be active (completing your daily gym workout or logging ‘ran 10 miles today’ on your marathon-training program) and still be sedentary (commuting every day to your desk job and consuming extensive digital entertainment during your leisure hours).

The perfect workstation

The key to finding health through an alternative workstation is to make sure your setup is as fluid as possible. The more time you spend at a ‘fixed’ station—even a super-fancy one with a five-star rating—the closer you’ll be to sitting all day. Standing is great after a decade of sitting, but with no refreshment of your mechanosensors (tiny sensors in your cells; see box, right), your body will simply begin a new set of adaptations to your new static position. And adaptations do not necessarily equal improvements.

So, if you sit cross-legged in your chair as you’re reading this, you’ll be doing your body better because you’re loading different parts. Try one ankle over your opposite knee. After a few minutes, switch to the other. The combinations at a workstation are endless.

Standing workstation kits

The standing workstation is a rather basic concept—move your keyboard and screen to a higher platform that doesn’t require you to sit in a chair. You can do this quickly and inexpensively with stuff you probably already have.

Prefab stand-up kits are stable and safe for office use, which can make transitioning at work easier if you need approval from your supervisor or human resources department. The only drawback, if you can call it that, is that a fixed setup might limit your options when your body needs to sit down.

Most upper-body parts are desperately underloaded and underutilized in comparison to the legs. The shoulder’s range of motion is mind-blowingly underused, and a bonus of the latest separated keyboards is that, if you want, you can work with your hands a greater distance apart than with the typical placement found in the usual keyboards. When you move your hands apart, the bones in your shoulder joint have to change position, which is a good thing for the muscles, blood vessels and nerves there. Issues like shoulder impingement syndrome (bursitis, bicep tendon tears) and thoracic outlet syndrome are brought about by insane amounts of stillness surrounding even more insane frequencies of tiny movements (like clicking your computer mouse).

Treadmill desks

There are indisputable benefits to treadmill desks; they allow you to keep moving in a way that’s great for your mind, metabolism and circulatory system. In one study, 18 subjects were given a text and emails to read while they either sat (control group) or walked at a treadmill desk. Ten minutes later, everyone was given a quiz on what they had read; those who were walking answered correctly a greater percentage of the time.3

Nevertheless, there are still many yet-to-be measured potential drawbacks that, over time, might have profound effects on your physiology and health.

To move through this world, you can either push backward, using muscle force to move forward (think of a paddle pushing against the water to move a canoe forward), or lean and fall forward, letting gravity do the work as your weight pulls you toward the ground in front of you.

Our natural, reflex-driven gait involves a big posterior push-off. This is a complex muscle-driven event that uses the lateral hip muscles, glutes and hamstrings. Walking or running in this manner keeps your torso upright and spine stable, loads the pelvis and hipbones optimally (strengthening them where they should be strengthened), and keeps frequent loads on your knees and hips at a level they can handle.

But this posterior push-off (rowing action) of the leg requires the ground to be stable. The belt on a treadmill is not fixed, but already moving in the direction you’d want your leg to be going, which means you need an entirely different way of walking to deal with a treadmill. When you’re on a treadmill, your body, instead of firing muscles to push back, is forced to catch up to the moving belt—which means you have to actively lift your legs up in front of you. While the walk may look the same, the pattern of muscle activation involved in walking on a treadmill is entirely different from what’s involved in walking on land.

The gait we are forced to use while walking on a treadmill is a recipe for future injury, the ingredient list being one part repetitive hip flexion (a movement pattern for which people visit a physical therapist to learn how to undo, in the event of particular injuries and disorders) and one part repetitive and excessive blows to the leg-stuffs (foot, knee and hip tissues) that are used to catch and cushion millions of tiny falls.

By using a treadmill, not only are you missing out on the many benefits of a natural gait (like strong glutes, which help support your pelvic floor), but you’re actually creating tiny negative outcomes that, over the long term, could add up to overworked knees, hips and lower back tissues, to name just a few.

If you’re currently experiencing musculoskeletal issues of the hips, lower back, pelvic floor or knee joint, then logging millions of hip-flexing steps could exacerbate these issues. Instead, build small actual walks across the earth into your workday—walk for three minutes every half hour of your eight-hour workday, and you’ll be moving for an extra 48 minutes each day.

Adjustable workstations

The best workstation is one that gives you endless options. It’s more helpful to think of every workstation as an adjustable one, as simply changing the way you sit can change your health for the better.

Whether you’re at a standing desk or waiting in one of the hundreds of lines you’ll stand in this year, you can practice standing in a way that uses more muscles actively.

The changes that allow you to stand without muscle force can damage your connective tissues, and the parts that would otherwise be supporting the body will then gradually lose their functionality. For instance, thrusting your pelvis forward when you stand, which forces tension in the quadriceps (the ‘four-headed’ group of muscles at the front of the thigh) and the psoas (the long muscle running between the spine from just below the rib cage to the top of the thigh—on both sides of your body—while attaching to all your lumbar vertebrae and spinal discs along the way) to hold you up, also takes the job of standing upright away from the butt and core muscles. Also, if you stand in one place for long periods—six to eight hours a day—those passive positions can do long-term damage to structures that don’t adapt well. All that rib-thrusting can overstretch the ligaments between vertebrae, and all that quad tension can weaken structures in your knees.

How your cells sense their environment

Cells in your body have parts with the specific function of sensing their mechanical environment (how the cells are positioned in response to forces created by movement and position). In a process called mechanotransduction, cell-shape distortions are turned into chemical signals that create adaptations in cells and tissues. Think of mechanosensors as fluid-filled balloons, then imagine squeezing the sides together, making the ends bulge out. Distortion of the mechanosensor (the cell’s structural change and resultant movement of fluid in it) is mechanical input—information that the cell can use to adapt.

The way we adapt depends on how we—our cells, really—are deformed. But it’s not only such cell deformation that signals a particular behavior; the frequency of cell stimulation is just as—if not more—important than the ‘load’ (the cell-deforming squeeze) itself.

It’s not only your trousers that stretch when you sit; the cells in your bottom deform as the weight of your pelvis presses into the mass that you sit on—like a ball of clay spreading out in all directions—so creating a particular signal within those cells (mechanotransduction). Research shows that sustained deformation of a fat cell can cause the cell to produce more lipids (fat) at a faster rate. What does this mean for you? It means get up and move!2

8 steps to better standing

The following is an eight-step checklist to help you stand better—meaning this arrangement uses greater muscle force to keep you in place, while decreasing the loads on the foot arches, knee ligaments and lower back associated with long-term body damage.

By going through these steps, you’ll be checking and rearranging the alignment markers that make for better whole-body use while standing at your workstation.

Step 1:

Feet forward

Align the outside edges of your feet with a straight edge, like a book or the edge of a mat. When standing still, this position optimizes the leverage of the foot’s arch-making muscles in the feet and hips. In Step 6, you’ll learn how to rotate your thighs, but you won’t be able to do that unless your feet are ‘neutral.’ Because you’ll be on your feet for a long time, you’ll want the muscles supporting your structure to be ‘on’ and active. In most people, the lower leg turns out as a result of excessive sitting and footwear use while growing up.

Step 2:

Feet pelvis-width apart

Place your ankles the width of your pelvis apart. Your hipbones should be directly over the center of your ankles. If your feet are closer together or farther apart, you’re creating particular loads on the knees that are associated with knee degeneration. Keeping your ankles at the correct width allows you to hold yourself up with the major muscle groups that do this job best, rather than relying on passive structures like your ligaments. Also, to (eventually) walk in better alignment, you need your feet to be pelvis-width apart to engage both the lateral hip and glute musculature needed to walk with good posterior push-off (as discussed about treadmills).

Step 3:

Legs vertical

Your pelvis (which contains your center of mass while standing) should be back over your heels instead of out over the front of your foot. When looking at yourself from the side (in profile), your hip joint, knee joint and ankle joint should all stack up in vertical alignment. The soft tissues in the middle of your foot can’t bear your weight as well as the giant heel bone in your rear foot, and standing with your pelvis out in front of your foot puts unnecessary loads on your quadriceps and psoas muscles which, in turn, puts unnecessary strain on your knees.

Step 4:

Pelvis neutral

The pelvis is made up of the anterior superior iliac spines (ASIS), which are the most prominent anterior (front) superior (above) bony projections on the right and left side of your pelvis. People often refer to these points as the hipbones (as in ‘put your hands on your hips’). The pubic symphysis (PS) is the midline joint where the two hipbones come together at the front of the body. It is the lowest bony prominence before your pelvis wraps around to the undercarriage.

Align your ASIS and PS vertically. Your pelvis sets the stage for your spine. Just as a vase can’t sit properly on a tilted table, your spine cannot sit optimally, relative to gravitational forces, unless your pelvis allows it to do so. Alignment of the pelvis is important when you’re standing all day long because the integrity of your spine (vertebrae, discs and spinal ligaments) depends on it. The tilt of your pelvis also affects the muscles that attach to it. Of particular importance when you’re up on your feet are the abdominal muscles. To keep your trunk muscles firing, they have to be at a length that optimalizes their ability to generate force. Excessive tucking in of the pelvis (or untucking it—also a problem) reduces the intramuscular leverage and, thus, the stability of the spine when maintaining a single position over time. You’ll want to be moving your pelvis (and whole body, for that matter) throughout the day but, in general, when you’re in place, maintaining a neutral pelvis means you’re allowing your lower back to maintain the appropriate amount of curvature for your particular stature (which means less back pain).

Step 5:

Ribs down

After aligning your pelvis, place your hands on your waist, then slide your hands up so they encircle your ribcage. With each hand, feel for the lowest part of your rib in the front of your body and drop those protrusions (each side being its own ‘point’) until the front part of the lowest rib is stacked vertically over the front of the pelvis. Your ribs should sink right into your abdominal flesh.

Your spine is connected to your ribs, so when you thrust and/or lift your chest, you’re bringing your spine along too. You can’t have a neutral spine without first having a neutral ribcage. When you lift and jut your chest out (which, I know, is often given as a misguided tip for better posture), you’re actually shearing some of the vertebrae in your lower back and forcing the vertebrae in your neck to adjust unnaturally as well. Lowering your ribs also adjusts the length of your diaphragm, allowing for better breathing.

Step 6:

Knee-pit neutral

Stand with your legs bare, feet straight and your back to a mirror. Now turn around to look at the backs of your knees (your knee pits) and you’ll see four lines (two on each leg) that mark the tendons of your hamstring muscles. Ideally, all four of these should align. Lower your ribs to neutral, and keep your knee pits directly behind you as your feet point straight ahead.

This means that your ankles and knees can best hinge in the direction you are walking, which is typically forward. Unfortunately, in most cases, these hamstring tendons don’t line up. To get them straight, most people will need to externally rotate their legs (rotate the front of the thighs away from each other). Do this while watching in the mirror, rotating them until you’ve brought all four lines to a neutral position.

Please note that it’s unlikely that your right and left legs will need rotating to the same degree. The turnout of our feet is rarely symmetrical, which means the correction won’t be either. When you’re first starting to align your feet and then your knees, it’s almost impossible to keep the sole of the foot in contact with the ground. Ideally, your feet should be much more mobile—but wearing shoes has clumped all the joints of the mid-foot together. For now, don’t force your feet to stay down when externally rotating your thighs.

Step 7:

Kneecap release

The position of your kneecaps is not fixed, but subject to the pattern of muscle tension in your thigh muscles. Balanced standing (that is, where all the muscles are encouraged to participate) doesn’t require constant tension in the front of the thigh. This means that, if your patellas (kneecaps) are locked into a knee-pit-neutral ‘pulled-up’ position, then your quads are doing too much of the work. Drop them by anchoring your weight back into your heels (which is where it should be in any case), thereby turning off the gripping motion of the quads.

Why should your knees be unlocked? Having ‘locked knees’ is a leg position that subjects the body to blood-flow-altering configurations—either hyperextension (when the knee joint sits behind the vertical line established by the hip and ankle) or constant tension in the quadriceps muscles. Just as your band teacher or military sergeant might have warned you, locking your knees all day long is one way to lose necessary blood flow. If you’re going to try and spend more time being upright during the day in the name of health, you’ll want to make sure that you stand correctly, so that all of you is healthier for it.

Step 8:

Head ramped up

Once your ribcage is in a neutral position, slide your head back toward the wall behind you until your ears stack up over your shoulder. But don’t pick your head up by the chin and don’t lift your ribcage to achieve this position. Each of these efforts is created by a lot of movement about a single hinge in the neck or back, which is not a good idea.

What’s better is to let the ramping motion be created by the efficient interaction of many joints. When you’re looking to fix the curvature of your spine—at any point between your head and pelvis—it is helpful to remember that curves are created by the actions of many parts. Ramping not only helps to restore the neutral curve in the neck, but also alleviates the excessive curvature of the upper back—a problem you may have only discovered you have when you aligned your ribs correctly.

Big movements to do at your desk

The following are exercises that will probably require you to take a work break. By taking three- to five-minute exercise breaks throughout the day, you can either practice just one of these movements per break, or you can flow through all of them in one break period. The results are entirely different, although both are beneficial in their own way. On some days, it’s good to work on each individual exercise so that you can reach a deeper level of proficiency. On other days, you can flow through all of them at every break to mobilize more of you more often.

Thoracic stretch

Place your hands on your desk or the wall. Keeping your hands in contact with the desk or wall, walk backward, dropping your chest toward the ground. Keeping your feet straight, push your pelvis up until your hips are behind your ankles, legs are straight (quads relaxed), and your tailbone lifted. Make sure you’re not thrusting out your ribs. For an added bonus, turn your palms and ‘elbow pits’ (the inside of your arm opposite the bony elbow) up. This is a great way to gently load the tension in the shoulder joints and de-mouse your arms!

Wall angels

Stand with your back against a wall with your feet about three to four inches away from it. Bring your hips and ribcage back until they touch the wall; this will stop you from thrusting your ribcage. Reach your arms out to the side, making a T, with your palms facing out (not toward the wall). Slowly, while keeping the backs of the hands and wrists against the wall, move your arms until they’re over your head, stopping once the arms or ribs pull away from the wall. Repeat in a smooth fashion, just as if you’re making snow angels against the wall.

Double calf stretch

This move places a great load on the tissues that keep your pelvis in a tucked position. Place your hands on the seat of your chair or on your desk. Line up the outside edges of your feet and straighten your legs all the way (quads relaxed). Back your hips up to behind your heels and make sure all your toes are liftable. While stopping your knees from bending and your ribs from thrusting, untuck your pelvis until you feel the muscles down the back of the leg. To intensify this stretch, externally rotate your thighs to neutral (alignment step 6) throughout this exercise to bring even more of your thigh muscle fibers into the stretch. Want even more? Place the front of both feet up on a half-round foam roller or rolled towel.

Stand Up for a Better Back

What Doctors Don’t Tell You is launching a ‘Stand Up for a Better Back’ campaign, to encourage our readers to stand up and vary their positions while working.

To kick off the campaign we thought we’d better walk (stand?) the talk ourselves. Three of us with aching backs from long hours at desks have worked for a month using Varidesks (available from, which enable you to sit or stand at various positions, with a simple mechanism that moves the desk height up and down.

Here’s how we’ve fared thus far:

Trevor Jayakody

Trevor, aged 36, our advertising manager, suffered from ongoing knee and lower back pain. Although his lower back was stiff after an hour of standing at his desk during the first week, he was surprised to see how readily his body adjusted.

By weeks three and four, he was standing for four or five hours at a time. He now feels far more flexible and has less tightness in his lower back and hamstrings, and has noticed improved seated posture. “Lower back pain feels a lot more stable,” he says. “Knee pain is much less severe and only happens after around four hours of standing.”

Joanna Evans

Jo, 34, our managing editor, was suffering with pain in her lower back, right shoulder and right hand, which an osteopath identified as related to poor posture at work.

Since switching to a standing desk, and varying her positions, “I did get some more intense lower back pain initially,” she says, “but after gradually increasing the amount of time standing, I found my back felt a lot better. I also get less shoulder, neck and hand pain.

“Now when I don’t stand up at my desk, I really notice the difference: all the aches and pains come back!”

Lynne McTaggart

Lynne has had intermittent lower back, hip and postural issues, which got exacerbated when she hurt the tendons surrounding one knee during a high-intensity workout. Months of limping resulted in some intermittent sciatic pain. Starting on a standing desk a month ago has been part of a holistic treatment using exercise and pulsed electromagnetic fields, which have healed the knee and ended pain. Although standing for more than 45 minutes caused aching legs at first, she is now able to stand for several hours at a stretch. “Remembering to vary position during the day and evening, even while watching TV, has also helped.”

Your challenge

Vary your position at work, and if you don’t have a standing desk, just pop your computer on top of a box or some books so it is eye level when you stand. Increase the time you spend standing every week. Write to us ( to let us know whether it’s helped your back.

Excerpted from Don’t Just Sit There by Katy Bowman (Lotus Publishing, 2016), available from Amazon

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