The Truth on Stand-Up Desks

You may have heard of the severe health consequences of prolonged sitting. In fact, prolonged sitting has been linked to issues from low back pain to a significant increased risk of death. Some have claimed that sitting is the new smoking. But is it really that bad for you? And if so, what are the solutions?

I’ll explore those issues briefly here.

So is sitting really that bad for you?

Some convincing evidence does show a strong relationship to decreased health, including depression, diabetes, heart disease, pain, and death, in those who sit for long periods of time.

I want to focus on the relationship of sitting to the two biggest issues: death and pain. First let’s focus on sitting and mortality.

Will sitting kill you?

Multiple studies have investigated the correlation between prolonged sitting and death. These are very difficult studies to perform, because there are so many confounding variables. For example, you can’t just take a group of people, study their sitting habits, measure the rates of death over time, then make a conclusion. For example, how is prolonged sitting measured… by accelerometer or self-report? What if people who sit more are obese, not working, and watch more TV? Maybe it’s those factors, not sitting itself,  that is really the problem.

This is just scratching the surface of all the variables to consider. That’s why you have to really look at how the study was done. Also, it takes several studies to often yield a conclusion. I’ll spare you the process of vetting the studies, and instead relay the conclusion from some recent ones that sought to tease out the confounding factors as best as possible.

Last fall, a study from the Annals of Internal Medicine made headlines by showing that there was a direct correlation between time spent sitting and a risk of death, regardless of the cause. Ann Intern Med. 2017.

The researchers tracked nearly 8,000 black and white people 45 yrs and older over four years and noted death rates. The average person sat for just over 12 hrs a day. The longer people sat, the greater the risk of death regardless of the cause, no matter their age, sex, race, body mass index or exercise habits. The big headline from the study showed that even those who exercised did not lower their risk of death if you sat for long periods of time. But it’s important to look at the specifics here.

For example, those who sat for 13 hrs a day had a 200% greater likelihood of death compared to those who sat for 11 hrs a day. What I found particularly interesting is that they didn’t just look at total duration of sitting, but rather at the length of sitting bouts. For example, those who sat for uninterrupted bouts for more than 90 minutes had a 200% greater risk of death compared to those who sat for less than 90 minutes uninterrupted. Those who sat for less than 30 minute bouts uninterrupted had a 55% less risk of death compared to those who sat for bouts greater than 30 minutes.

However, the negative effects of uninterrupted bouts of sitting were not significant for those who were not sedentary (i.e. did not sit for more than 12 hrs a day). So if you aren’t sedentary, bout duration didn’t have a big effect. But if you sit for more than 12 hrs a day, and these bouts are longer than 30 minutes at a time, then your risks of death are even higher.

So what do we know so far about this?

If you sit for long periods of time, try to do it less than 11 hrs a day, and get up and move every 30 minutes. The big part that got the media’s attention was that if you sit more than 12 hrs a day, then go exercise for an hour, it doesn’t negate the risk factors associated with prolonged sitting.

While this is helpful, other studies found that when you more specifically define exercise and the type of sitting (i.e. at work or in front of a TV), stronger conclusions about the role of physical activity were found.

For example, three well-controlled studies of thousands from Briton, Norway, and Denmark (Stamatakis E , et al. Br J Sports Med January 2017. Petersen CB, et al. Br J Sports Med February 2016. Åsvold, B.O., Midthjell, K., Krokstad, S. et al. Diabetologia (2017) showed that prolonged sitting was not correlated with disease or death when obesity and activity was controlled.

A meta-analysis consisting of 16 studies of over a million people showed that in those who were highly physically active (60-75 minutes of moderate to vigorous activity) were able to eliminate the risk of death associated with prolonged sitting, and attenuate the risk of TV watching. They found that those who were not obese, not diabetic, and did not sit > 1 hr a day watching TV, had no increased risks of mortality of disease, even if they sat at work for 8 hrs per day. Biswas A, et al. Ann Intern Med. 2015

The same study did show increased disease and mortality rate for those who sat > 8 hrs / day that were moderately active, and more so for those who were inactive. For these people, prolonged sitting was equal to smoking and obesity as a risk factor for death. Even more interesting was that sitting watching TV was associated with increased mortality compared to sitting doing work.

These studies seem to contradict the conclusion from the first study that regardless of how active you are, prolonged sitting is harmful. However, the first study failed to look at the effects of high activity levels like the previous study. Also, the other studies accounted for the effects of obesity and diabetes. The findings are mostly in agreement when you consider these factors.

So far, here is the take home from the evidence:

Unless you are very active, more sitting increases your disease and mortality risks. Even more so if you are not active. If you are inactive, when you sit for bouts longer than 30 minutes at a time, you have increased mortality risks. Sitting in front of the TV is worse than sitting at work.

So Should We Stand More?

Let’s say getting 60-75 minutes of moderate to vigorous activity isn’t a reality for you, and you have a two hour commute each day, and work 8-10 hours sitting at a desk, and God forbid you like to settle in for an hour of Netflix to wrap up your day. This means, like most people, you are at a higher risk of premature death, even if you squeeze in a couple hours of exercise a week.

Given that relocating closer to work and quitting your job isn’t feasible, how about getting a stand up work desk?

Will getting a stand up desk make you more healthy?

Some speculate that decreased calorie burning is why prolonged sitting is so harmful. Accordingly, if people burned more calories, they would have less risk of death and disease. This explains why those who were highly active in the prior studies did not suffer the negative effects of prolonged sitting compared to their less active counterparts.

To follow this line of thinking, researchers would have to prove that standing vs sitting burns more calories. Gibbs, B. et al.( Occup Med (Lond). 2017 Mar) showed that alternating sitting and standing increased calorie burn by 8%, and replacing prolonged sitting with >4hrs of standing increased calorie burn by 11.5%. This could translate to an increase of 57 calories for the average size man.

Another study found that in 15 minutes standing, sitting at a computer, or sitting watching TV you burn 22, 20, and 19 calories respectively. So in 4 hours, you can burn an extra 32-48 calories by standing. The same researchers found you can burn more than that (56 calories) by just getting up and walking for 15 minutes. Creasy S, et al.. J Phys Act Health. 2016.

While it does appear that standing may be a good alternative to prolonged sitting for your health, if its effects are related to burning more calories, its effects are small.

Accordingly, based on the evidence thus far, if you hope to improve your health I would recommend:

1. Change your sitting position frequently (every few minutes)
2. Get up and move frequently (every 30 minutes)
3. Get up at work, standing up for 20 minutes every hour
4. Get up and take a walk every hour or two ideally, but at least take a 15 min walk every four hrs of work.

What about back pain and sitting?

This gets a little more complicated.

The biggest reason why is that low back pain isn’t a homogeneous condition. It’s like saying someone has a learning disability. Obviously there are different types, causes, and thus treatments. Unfortunately, no studies have investigated prolonged sitting and its effects on specific types of low back pain. However, using the general classification of low back pain, there does seem to be a strong correlation between sitting and low back pain.

Accordingly, it would seems then that doing more standing instead of sitting is a good option. However, the studies on this are mixed. That is to be expected, because as previously mentioned, low back pain is a multi-factorial issue, one that is likely not to be solved by one intervention. Also, just because prolonged sitting is bad doesn’t mean that prolonged standing is good.

Prolonged anything is in general a bad idea for the human body.

So let’s take a quick look at the science on this.

Support for less sitting to fix your back

Several studies have boasted the positive effects of reducing sitting time on back pain. A study in 2011 looked to more directly assess the relationship between the intervention of simply providing desk workers with a sit-stand desk. Twenty-four workers participated in the intervention group, 10 did not, and thus served as the control. (Pronk NP, et al. 2011. Prev Chronic Dis 2012).

Over the next seven weeks, the intervention group reduced their sitting time by 66 minutes per day. The control group increased sitting by 17 minutes per day.

Upper back and neck pain declined in the sit-stand desk group. But, after the seven week experiment was over and the sit-stand desk was removed, the incidence of upper back and neck pain returned.

Interestingly, there was no difference in low back pain or time spent in physical activity breaks between the stand-up desk group and the control group. This means that you can’t credit the improvements to interventions other than the less duration of standing, like being more active.

It was also found that mood improved for the sit-stand group, but these mood improvements were lost once they went back to sitting for two weeks. They also reported feeling more productive, focused, energetic happier, and less stressed. There are some problems with this study, however. First, there were few participants and they were not randomized. Second, all outcomes were self- reported, which may not be reliable. More about this later.

A well-designed study in 2015 gives us some better data to make conclusions about stand up desks and low back pain. (Gupta, N. eta al. PLoS One. 2015; 10(3). The researcher found that among 201 blue collar workers, high sitting time, not just at work (>3.7 hrs.) but also in leisure (>5.4 hrs.), correlated with high low back pain.

This researcher mentioned a very important point that should be appreciated. Their research review identified many studies that showed a correlation between sitting and increased low back pain, and several that showed no correlation. They note that there are several reasons why there may be conflicting findings. The biggest is perhaps that sitting time is measured by self-reports, which could be highly unreliable. However, in this study they used accelerometers to objectively measure activity.

 Another factor could be the heterogeneity of the population in terms of socioeconomic factors, which can confound outcomes, as socioeconomic factors tend to correlate with low back pain. However, in this study they attempted to control this factor by only including blue collar workers.  In addition, many of these studies did not report leisure time sitting and work related sitting. This could be significant, as overall duration of sitting can vary significantly outside of work. In this case, all workers were blue collar workers, and their sitting time both in and outside of work was assessed via accelerometry

Recently, a meta-analysis was published that concluded the utilization of sit-stand desks does reduce low back discomfort.  (Shuchi Agarwal, et al (2018) Ergonomics, 61:4, , ) However, the level of discomfort resolution was low. This was expected, however, because in all of the studies included in the meta-analysis those with pre-existing back conditions were removed from the study. I found this odd because it would be meaningful to see if sit-stand stations were viable interventions for those who are actively experiencing back problems.

Regardless, since meta-analyses are some of the strongest types of research, it’s important to know that this evidence showed a small and significant effect for the sit-stand intervention in reducing low back discomfort.

Unfortunately, the studies included in the analysis used a wide range of sit-stand ratios, thus a specific dosage cannot be recommended.

Questioning the Use of Standing Tables on Reducing Back Pain

However, since then a few studies have called into question the utility of standing desks for treating low back pain. In fact, they found using standing desks actually increased low back pain.

Earlier in 2018, Viggiani and Callahan from the University of Waterloo tested 40 adults with no history of low back pain, and 40% of them developed low back pain after standing for two hours but pain dissipated within 10-15 minutes of sitting down.  (J Appl Biomech. 2018 Feb 1;34.) This really isn’t that surprising; given some people will have a greater standing tolerance. But, it does give pause to the idea that simply standing is better for back pain.

Also, earlier in 2018 research from Curtin University found that standing desks create discomfort, deteriorating mental reactiveness, and increased ankle swelling. Twenty people were part of the study in which they were exposed to working for two hours uninterrupted while standing.  It wasn’t all bad, however, as creative problem solving improved. Richelle Baker, et al (2018) Ergonomics, 61:7,).  Again, this isn’t surprising. Few clinicians would advocate for standing uninterrupted for two hours.

Another study with 96 participants found that those who used prolonged standing desks were more uncomfortable, and did not show any change in mood, creativity, or performance. However, they did show greater task interest, enthusiasm, and alertness. Finch, et al. Int j environ res public health 2017.

 Confused by the conflicting findings?

While it seems like the studies are disagreeing, they really aren’t. They are just highlighting that there are nuances about this topic that can’t be covered inferred from a click bait title in a FB post.

A very recent randomized control trial does a great job exploring the practical use of sit-stand desks by those with LBP, which addresses a problem with the prior studies that I mentioned earlier. (Gibbs et all Occup Environ Med. 2018 May;75(5):321-327)

Researchers looked at the effects of changing sedentary behavior on 27 people with LBP who have desk jobs involving sitting for more than 20hrs/week.

In addition to providing them with sit-stand desk attachment, they were given behavioral counseling, cognitive behavioral therapy for LBP, and a wrist worn activity prompting device.

The intervention group reported a 50% decrease in disability compared to 14% decrease in the control group. As mentioned before, however, there are problems with this study: sitting time was self-reported, and sitting outside of work was not assessed. Also, multiple other interventions were utilized, so we cannot attribute improvements solely to the sit-stand device.

Let’s summarize the evidence about using sit-stand desks for low back pain.

I’ll also throw in my clinical perspective, and wrap this up with combining my overall recommendations of sit-stand desks for both LBP and for general health:

Using sit-stand desks for LBP:

• There is good evidence that using a sit-stand desk may reduce LBP or musculoskeletal discomfort.
• There is evidence that providing a sit-stand desk will decrease the amount of sitting time.
• There is poor evidence regarding the optimal dosage of a proper sit-stand time.
• There is evidence that prolonged standing (ie > two hours) may increase low back pain.

 My Final Verdict:

More studies need to be done on those with active low back pain pathologies. Specifically, these studies need to both specify the type of workers and the type of low back condition that they are experiencing.

For example, I’d like to see a study on office workers who baseline sit greater than 25 hrs. a week, measured via an accelerometer (or similar device) who are 35-50 years old suffering from intermittent discogenic, flexion sensitive low back pain treated with a one month intervention of  regular physical therapy plus utilizing a sit-stand desk with varying degrees of sit-stand rations, measuring their compliance, and comparing the outcome to those receiving the identical physical therapy, but no sit-stand desk. That would allow us to provide some clear, meaningful recommendations.

Related to the above, we must appreciate that different types of people with different types of back problems are going to respond to different types of treatments related to sit-stand recommendations.

For example:

• If you are younger, have intense pain when you bend forward, and you sit for work…, it is likely that you will feel much better if you sit as little as possible. Accordingly, a sit-stand desk will change your life. Get one. But that doesn’t mean you stand for two hours at a time. Still take frequent sitting and walking breaks.
• If you are older, straightening up increases your back and leg pain, but bending forward makes it feel better… it is likely that prolonged standing is going to make things much worse, A standing desk is not going to be a good option for you.
• If you are not in good shape or are overweight… you will not tolerate prolonged standing as well as others, but you should still change positions and get up frequently. Just keep in mind that you will need to adjust your sit/stand ratio accordingly, and your standing tolerance will improve as you lose weight and get stronger.

In all cases, any prolonged positions are not good for your back or your health. Change positions as frequently as possible, and get up and move as often as possible. Ideally, do this every 30 minutes. Don’t confine your options to just sitting or standing. Take a walk. Even better, do a dynamic warm up, or at least components of it. You can do that anywhere, and you don’t need to even leave your work space to do it.

You don’t need further evidence before you act on this advice. Yes, there is seemingly conflicting advice about the use of a stand up desk. There is less conflicting evidence of using a sit-stand workstation. I’ve explained some of the reasons why there is conflicting information above. In light of this lack of absolute certainty, the best way to proceed is to determine: 1. Is it likely to be effective for me? And, 2. Are there significant risks for me? Given that the risks are low or nil (unless you go overboard and switch immediately to standing all day tomorrow) and the benefits are positive, for the majority of people, I advise that they:

1. Have a work station that allows them the option to easily work while seated or standing.
2. Get up and move every 20-30 minutes.
3. Take a short walk a few times a day.

If you aren’t sure how the risk/benefit ratio works in your case, please reach out and let me know. As with most things, the goal is not making generalities from the science (that’s what researchers do), but taking the findings and applying it to a specific individual (that’s what coaches and clinicians do). If you are looking for a sit-stand desk, here are a few options to consider:

www.ergotron.com/products/stand-up-desks/desk.conversions,

www.versadesk.com,

www.veridesk.com