The Truth About Sitting and Stand up Desks on Health and Back Pain

The Truth on Stand-Up Desks

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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?

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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:

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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?

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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)

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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:,,



New Ownership Press Release

Michael Stare                                                                                                   FOR IMMEDIATE RELEASE

Orthopaedics Plus Physical Therapy

100 Cummings Center Suite 121Q

Beverly, Ma 101915



Physical Therapy Icon Doesn’t Sell Out, Instead Leaves Legacy and Grows from Within

Orthopaedics Plus Physical Therapy changes ownership, retains founder as a clinical expert.

Burlington, Beverly, MA – When you’ve lead a thriving business for over 30 years in the health care arena, it’s unusual to walk away without being swallowed by the big hospitals or acquired by a large company with hundreds of clinics. Yet, by handing the reigns over to two of their younger clinicians, that’s exactly what co-founders and former owners of Orthopaedics Plus Physical Therapy, Al Visnick, Bill Antonelli, and Vinny Buscemi have done. But they certainly are not going away.

“Our goal was to leave this business as a legacy of what we believe Physical Therapy should be. The ones that I trust to do that are Justin Pezick and Mike Stare, who have the same standards that we have worked hard to create. No large hospital system or multi-region practice would be able to keep that legacy alive” says Visnick, who is guiding the transition process and remains as a treating clinician. “So I’m not going anywhere, I’m just done with the day to day business aspects” clarifies Visnick. Fellow Orthopaedics Plus Co-founders, Bill Antonelli and Vin Buscemi, will continue their roles in managing the physical therapy services for Winchester Hospital’s Outpatient Physical Therapy Clinics.

With offices in Burlington and Beverly MA for 31 and 20 years respectively, Orthopaedics Plus is one of the oldest surviving independently owned PT Clinics in New England. And with 9 of its 13 clinicians possessing between 15-30 years of clinical experience, it’s also one of the most seasoned.

“The 2 biggest factors that made this such a great opportunity to take over ownership is the culture of top-notch patient care that Al, Bill, and Vinny have fostered, and the amazingly talented group of clinicians we inherited” says Dr Mike Stare, who has worked with Orthopaedics Plus for over 14 years as a Physical Therapist in the Beverly office.

As the founder and owner of Spectrum Fitness Consulting for the last 12 years, an award winning personal training studio also in Beverly, Dr. Stare is no stranger to running a business. In his new role as owner of OP, he plans to incorporate many of the lessons he learned growing his fitness studio to his new role as owner of OP. “Helping patients recover is more than making them feel better and get out of pain. It’s about improving their overall wellness and getting to the cause of their issues. Physical Therapy is more than treating knees and backs, it’s about treating people…listening to their goals, caring, and problem solving. To do that, you have to educate them not only when they are patients, but reach out to the community before they are patients.”

Dr. Stare is not shy about reaching out to the community, as he has provided hundreds of seminars and workshops to business, schools, philanthropies, and various groups on injuries, health, and fitness. He also travels nationally teaching thousands of clinicians across the country.

It is the role of educating clinicians that new owner, Dr. Justin Pezick, a clinician in the Burlington office, hopes to continue advancing at Orthopaedics Plus. “OP is responsible for educating many of the top clinicians in New England. Both Mike and I as younger clinicians came to OP earlier in our careers because of their reputation and skill in developing top level clinicians who provide the best care. We have amazing clinicians, and hope to utilize their expertise and experience to continue developing the best clinicians for years to come”.

Dr. Pezick’s skill in modernizing technology and updating billing practices has already paid dividends. “That’s another amazing thing about this partnership transition. Justin has skills and interests that Al and I don’t have, which have already improved operations, profitability, and enhanced patient care” explains Stare.

While Stare and Pezick have taken over OP in January, 2018 with a list of initiatives to enhance the practice, what is most important are the things that won’t change. “Our vision is to keep the key principles intact; retain the most experienced clinicians who get to spend enough time with their patients, something that is becoming less common in PT”, states Pezick. “Furthermore, Al Visnick will remain as a clinician and Director of Treatment in Bulrington, continuing to treat patients in the Burlington clinic. In addition, Ellen Poveromo will remain as the Director of Treatment in the Beverly clinic. Al and Ellen are such an important assets, so retaining them as expert clinicians is something we are thrilled about.”

Dr. Pezick, who also shares a similar background in fitness as his new partner, aims to expand upon the traditional role of Physical Therapy care. “To address the goals of patients, we need to go beyond rehabilitation, and incorporate wellness into the clinic.” With expertise in Athletic Training, Strength and Conditioning, nutrition, and fitness, along with fellowship training in manual therapy, the new owners are well poised to introduce these practices into their clinics. “We have an all-star staff, each who have exceptional expertise beyond general orthopaedics and spine care including pelvic floor dysfunction, scoliosis management, weight loss, post-masectomy care, athletic performance, and more” adds Stare.

While most of what Orthopaedics Plus is known for will remain the same, the new owners do have changes in mind. “The change current and returning patients will notice most is an upgrade in the physical clinic in Burlington.” says Pezick, who is planning renovations to be ready by the end of the year.

“In addition, we strive to make the following changes: 1. Dramatically increase awareness in the Beverly, Burlington, and surrounding communities of our unique and advanced care opportunities. 2. Expand opportunities for clinicians to further develop their clinical expertise through providing specialized care and education programs and 3. Advance our clinical education program to develop and train clinicians seeking advanced post-doctorate specialization.” States Stare.

“Our goal is not primarily to grow through expanding clinics across New England. Rather, our goal is to focus our efforts to be the most effective, sought-after provider for physical therapy. And we want to be the place where top level clinicians who love what they do come to learn, and stay to treat for the rest of their careers. That’s the formula we’ve seen last through decades of treatment trends and health care changes to best help patients.”

With the new ownership at the helm and Visnick in the clinic, he’ll have a great perspective to see his legacy plan unfold with Orthopaedics Plus. “I think we’re well poised to be around for another 30 plus years.” Says Pezick.

Knee Arthritis and Weight Loss

Does gaining weight cause knee arthritis? Will losing weight reverse knee arthritis, or at least make it better? What should I do if I have knee arthritis and I want to lose weight?

Answers to all of these questions are addressed here, back by all of the latest evidence. Check out the evidence and solutions all wrapped up in a few minutes by watching this video that explains it all.

Why Your Joints Crack – Is It Bad?

The sounds of a popping, cracking, clunking or grinding joint can be a powerful force. For some, it may signal potential doom, fearing they just broke something or that they put a joint “out of alignment”. For others, it is a welcome sign of relief, signaling that they “put their joint back in place”. Most of us simply want to know ‘what the heck was that, and is it bad?

This is important because the fear and uncertainty these sounds evoke will often keep people from exercising. Others will seek dangerous or ineffective methods to provoke the “crack” in search of a false hope for solving what ails them.

Hopefully what follows will clear up any confusion and give you the confidence to know if you should just move on or be concerned. At the very least, I think you will be entertained, and feel special that you have fodder for a know-it-all moment next time someone cracks their knuckles at a cocktail party.

Will You Get Arthritis If You Crack Your Knuckles?

Most of us are familiar with the wives tale that cracking your knuckles will lead to arthritis. A very cool study helped determine if this is true.

Decades ago an 8 year old boy was always told by his grandmother that his frequent habit of cracking his knuckles would give him arthritis. So the boy set out to investigate the validity of this advice (like any normal 8 year would do, right?). From that day on, each day he would crack every knuckle on this right hand only for the next 52 years. The boy eventually became a rheumatologist (of course) and on his 60th birthday he decided to x-ray his right and left hand to investigate the differences between the chronically cracked joints on the one hand compared to the other which had been left alone (this guy knows how to party). The result? There was absolutely no difference between hands. Makes me wonder what lengths the boy went to determine the validity of the Easter Bunny.

So it appears grandma was wrong. Popping your knuckles won’t cause arthritis. But that doesn’t completely answer what is going on when we hear that pop and crackle from our joints. Let’s take a deeper look.

Getting Out Of Line?

A common trick that many Chiros and some PTs use to instill fear and dependence in their patients is telling them that they are out of alignment, and the magic manipulation or activator (done several times a week for the rest of their life of course) will solve all problems and put them back in line.

Before I go further and unintentionally evoke the sentiment that I think joint manipulation (often resulting in an audible pop) is a sham or dangerous, I want to be clear: joint manipulation can be very therapeutic and has good evidence to back it up. I spent 2 years of my life in an intensive post doctorate fellowship program to learn the nuances of spinal manipulation and use it with my patients and family members.

But I get very critical when people justify its use based on the fantasy of realigning structures to evoke a sense of dependence while dodging the real cause and solutions for their problems. Doing so in the absence of any evidence that supports such a phenomenon is even more problematic.

This needs to be etched in the doorway of any manual therapist, chiro, or osteopath: manipulation will not realign your joints. Never. Ever.

Now, I don’t blame you if you thought it would. It seems plausible on the surface. Plus, this has been passed on as if it were common knowledge. Even as a trained clinician, in my early years I thought it might be possible to realign joints by manipulation. But the more time I spent learning about manipulation and working with people who had various joint problems, especially spine issues, I realized how simplistic and ridiculous this notion was. Let’s consider some common occurrence to see if realigning joints seems possible.

The force required to induce a manipulation is far less than many forces sustained in daily life. Consider a cough or sneeze. If the realignment theory holds true, than the reverse must be true as well. Surely the forces of a good sneeze, if they exceed those produced at the hands of a therapist, could put us out of alignment. If we get a cold or suffer from allergies, are we doomed to be malformed like Quasimodo? And God forbid if we fall or, gasp, play sports and make contact with another player, kick a ball, or swing a bat. This would certainly cripple us!

Clearly, it just doesn’t make sense that we can so easily be put back into alignment as much greater forces don’t put us out of alignment.

Chiropractors say they are realigning your spine by reducing a subluxation. Essentially, as the fairy tale goes, your spine has been temporarily dislocated, and they are relocating it. The fact is that forces that would be required to actually sublux our spines would cause fractures of the spine and consequent nerve damage. So it’s darn good that we can’t have such subluxations (without serious trauma). These are the figments of an overactive chiropractic imagination, not phenomenon that take place in reality and validated by science.

But wait, the x-rays show it? Yes, only when read by someone unskilled in radiology or biased with subluxation fantasy. Sure there will be alterations in spine position (scoliosis, etc) but these alterations could be habitually selected postural anomalies by the brain, or permanently altered shapes of the bone. For example, imagine someone taking a whole body x-ray of you while standing with a sharp pebble in your shoe. Naturally, you would sift your weight away from the painful side. On x-ray, you would be in “misalignment” but this is clearly due to your brain telling you to redistribute your weight away from the pain rather than some joint alignment problem. What happens when you remove the rock from you your shoe? Viola, your alignment improves. If a manipulation was done, that would be the smoke screen masking the true solution (remove the pain provoking stimulus), and the x-ray serves as an attempt to legitimize the rouse.

Clearly, if this simplistic alignment theory were true, wouldn’t you think scoliosis and kyphosis would be a thing of the past? You can’t just put the spine back in place with your hands.

What Is That Pop?

So let’s get back to the issue of what’s cracking. The audible pop associated with joint mobilization/manipulation is usually due to cavitation in which two joint surfaces are temporarily (and minimally) separated, causing gas to be released from the joint space. This can often result in mechanical, neurological, and psychological events often resulting in pain relief.

Mechanically, the release of pressure from the joint may reduce sensitization to hyperirritable joint tissue. But the effect is not because we have magically placed the joint right back into the right position.

More convincing is the neurophysiologic effect, in which afferent stimuli triggers the release of neurotransmitters in the brain which help modulate pain. A recent study revealed a few such mechanisms that manipulation can trigger. (Gustavo Plaza-Manzano, et ak J Orthop Sports Phys Ther 2014;44(4):231–239) Again…nothing is being realigned, but the chemicals in our brain that influence joint pain perception may be altered.

And finally, the well known placebo effect may be at play. This is a very strong and real response, in which if someone firmly believes something good (or bad) will happen when they experience this manipulation, validated by the pop and the surface logic of “realigning” them, then they will actually feel better (Ernst E. Family Practice 2000; 17: 554–556.) If they believe it will work, often times it will.

Addicted to Crack?

“Yeah but, it really works for me!” I know…I believe you.

That’s why I use it, and have it done to me. But it has limitations, it’s not magic. Sometimes it works, many times it doesn’t. The debate is really why, how, when, and for whom. Studying the research and treating patients will answer the above to the extent that we can use it wisely.

So what’s the harm of getting cracked if you find it works for you? Complications, sometimes severe, have been reported mostly in regards to cervical manipulation. But these issues are very rare, and are greatly reduced by proper screening and technique. More common, but less severe, are the extreme positions many people put themselves in trying to desperately get that pop. I have witnessed many folks who are Gumby hypermobile contorting themselves to positions that are putting extreme stress on known vulnerable tissues in their spine which are often the source of pain in efforts to get the desired “pop”. This is like ripping open a wound in attempts to scratch an itch.

A very significant and common harm is that it could force you to bark up the wrong tree. Let’s say you woke up with an achy back. You seek out your favorite “bone cracker” and “crack”…ahh, you feel relief! Very Cool, right?

Yes, immediate relief is possible (not very common though if you see multiple types of spine clients). But just as important, and perhaps more so, is figuring out what caused the pain in the first place? Without finding the cause, how can we assure it won’t come back? Usually poor ergonomic and faulty motor patterns are contributing factors. I often tell patients that doing treatments (manipulation, mobilization, exercise) without addressing ergonomics and habits contributing to the problem is like taking Tylenol for a head ache while repeatedly banging your head against the wall. Related to this, instability is often involved. What will manipulation do to address these issues? Absolutely nothing.

Focusing on manipulation at the center of treatment often marginalizes the importance of these other well supported contributing factors in the minds of the patient. It also places the locus of control away from the patient. This creates a “you fix me” psyche resulting in dependence, not empowerment. The result is a cycle of pain, visit, crack, pain, visit, crack…and a crack addict is created!

Us clinicians should be a bit more humble about our treatment methods and provide the facts about what is and what is not happening. Doing so creates not only trust, but an environment that empowers the patient to look to factors that they can control and have a positive influence upon their pain. This approach is strongly supported by research and real world results. (Gustafsson M, Gaston-Johansson F. Pain intensity and health locus of control: a comparison of patients with fibromyalgia and rheumatoid arthritis. Patient Educ Couns 1996;29:179–88. Crisson JE, Keefe FJ. The relationship of locus of control to pain coping strategies and psychological distress in chronic pain patients. Pain 1988;35:147–54)

Demystifying the crack at the hands of a clinician is one step in helping us focus on the other less sexy but more supported mechanisms of addressing joint problems.

Snap, Crackle, Pop…

The sounds of a pop at your spine and knuckles are familiar to most of us, but we hear these noises and others in our other joints, especially our knees, shoulders, ankles, hips, and even our shoulder blade. Here’s what is up some of these common noises.

Knee popping. A loud pop is common when movement occurs in a stiff joint (especially after periods of prolonged immobilization). This is rarely painful. In fact, it might feel good. Regardless, there is no evidence of any correlation to joint damage or pain when this occurs. As one of my professors taught us in summarizing the research on this “if you hear a lot of cracking, turn up the radio”. For those of you who are quite literal like me, this mean don’t worry about it.

There are times when you get a loud pop at the knee when something really bad happens. This is often reported when a ligament ruptures like the ACL. The noise, however, is not from the ligament rupturing. Pulling apart a tissue like that wouldn’t usually make a noise. Rather, the pop or “thunk” is usually the joint subluxing or separating, like popping a knuckle, only louder. This happens with pretty extreme trauma, like while skiing or playing basketball, not exercising. Even when I ruptured my patella tendon right in half, there was no sound (other that of my back hitting the pavement).

Knee crackling, like grinding sand, is very common at the patellofemoral joints. This is very common when going up and down the stairs. The crackling of my wife’s knees going up the stairs is loud enough to hear throughout the house. Yet she works out intensely without issues. And that is not uncommon. Some have speculated that the grinding noise is due to softening or irregularity of the joint surface of the knee cap. When this irregular surface rubs over the surface of the tibia under load (like when squatting or ascending stairs), this makes a noise like a shoe with sand on the sole rubbing over the floor.

My knee following the several trauma of a patella tendon rupture is an interesting case study to investigate this theory. As a result of attempting to repair the patella tendon and restore functioning, the resultant length of the tendon, and accordingly the position of the knee cap, was permanently altered. This changes the surface area contact of the patella upon the adjacent tibia joint surface, and also the force mechanism of the muscles and tendons acting on the joint. Accordingly, when I was finally able to ascend stairs, the noises my knee made were quite disturbing even to a seasoned clinician. I moved forward with confidence, knowing that there was likely little damage going on, and the consequences of not gradually strengthening my knee were far worse that the consequences from the noises common from my knee.

A few years later, my knees rarely make any noise with stairs. My theory is that the articular surface of my knee cap softened due to the months of immobilization. Upon reloading it, coupled with the altered surface area being loaded as the consequence of my knee being structurally altered, the tissues were irregular. However, over time with graded loading, the joint surfaces adapted and smoothed out, thus resulting in minimal noises. We witness this in the clinic many times. Folks who have been immobile will hear some unsettling sounds when new movements are restored. They should be encouraged to continue moving and reassured that over time these noises may dissipate. Again, we have no proof that the noises are bad or good in these cases. However there seems to be a common pattern of joints getting less noisy with more movement after immobilization.

Clunky Hips

When hips make noises, we often hear a deep ‘thunk’ or a superficial snapping. The deep thunk is common in those moving after a period of immobility, just like with the knee example above, or in those who are hypermobile (dancers). These issues are rarely indicative of any problems. The superficial snapping can correlate with pain. This can occur from a tendon moving over an inflamed or thicken bursa, or a tendon gliding over a boney anomaly (such as a bump on a bone). Interestingly, I see this more often in women with a wider pelvis, and it often gets better with strengthening the glutes, stretching the hip flexors, and improving lumbopelvic stability. Several theories can explain why or how, but given that it is a low risk intervention that can help many other issues, proceeding with this approach without fully understanding the mechanism is something I feel very comfortable with.

Clicking Shoulders

Given the similarities between the shoulder and the hip, similar phenomenon are found there as well. The key difference is that shoulders have a much greater degree of mobility and far less stability. So joint irregularities, noises, and damage are all more common there. In the clinic I find those with greater amounts of mobility (swimmers and baseball players), those with significant arthritis, and those with poor scapula thoracic and scapula humeral function tend to have more noisy shoulders. Just like with the other joints mentioned, those who are immobile will experience more noises when they attempt more movement, but then over time this noise often diminishes.

Again, we can’t conclude that joint noises are always related to pain, as we commonly see painful silent shoulders, and vice versa.

Those with instability and poor shoulder mechanics need these issues addressed, which basically involves movement. So again, the noises should not discourage us from moving out of fear that joint damage will result.

Snapping Scapula

Finally, a less common site of “joint” noise is at the shoulder blade, sometimes referred to as snapping scapula. This snapping can occur with or without pain and has been suspected to be caused by a few possible issues. First, atrophy of the underlying subscapularis and serratus muscle alters the interface between the scapula and the bumpy rib cage over which it glides causing the superior angle of the scapula to catch upon the underlying bone. Also, the two bursae that lay between the scapula and the ribs may become thickened, altering the surface area between the bones of the scapula and rib cage. Finally, anomalies of the ribs (bumps on the bone) can affect the articulating surface causing snapping.

Should You Be Worried?

The most important issue when you get any symptom is to know if you should be concerned and worry. Hearing noises coming from your joints can be unsettling. As we reviewed above, it should be clear that rarely does joint noise tell us that something bad is happening. In fact, more often it will indicate that we should move. There can be many obstacles that clutter our road to improved health and fitness, so it’s important that we clear our path as much as possible. Hopefully we’ve cleared another obstacle from your path. So if you hear noises, be calm, and proceed to improving your movement quality. Just as important, don’t chase noises under false pretenses of realigning joints.

Most important, be sure to reach out if you need to know how to ensure you are doing the right things based on your unique needs to reach your goals.

Thoracic Spine Mobilization

When shoulder range of motion is impaired, the most common response is to address the shoulder joint. While this seems to make sense, it is not usually the best solution.

Shoulder range of motion is intimately related to thoracic mobility, or the mobility of the middle of your back. Full shoulder range of motion is possible only if there is adequate thoracic extension. Accordingly, in many cases thoracic mobility is a significant contributor to a lack of shoulder range of motion.

Most people have stiff thoracic spines because of poor training habits and poor posture. The best way to improve thoracic mobility is through manual mobilization at the hands of a skilled therapist. However, another great, simple option is to use a foam roll.

While this is commonly suggested, I think the way most people are instructed to do it poorly addresses thoracic joint mobility into extension, and instead focuses on mobilizing the muscles of the thoracic region. And this is a big difference. The goal of mobilizing the thoracic spine to improve shoulder motion is to specifically increase gliding of the joint surfaces to allow for increased thoracic extension. Accordingly, we need to as best as possible stabilize one region so the other can glide in a manner to increase extension.

However most people are rolling back and forth on the roll to reduce the soft tissue density of the muscles, thereby increasing extensibility. The only range of motion this will improve is flexion, or bending forward, which is the opposite direction you want your spine to go to improve shoulder mobility.

Spectrum trainer Dave Knight, ATC, CSCS, ISSN demonstrates a great way to increase thoracic extension mobility with a foam roller below:

Is Your Stiff Low Back Really Stiff?

If you are like 80% of the human race, you’ve likely complained of back stiffness. That would seem to indicate that your back is need of stretching.

This seems to make sense on the surface, but recent research calls this into question.

As I often say, however, just because it’s logical, it doesn’t mean it’s physiological.

Just because you feel stiff, doesn’t mean you should stretch.

For years I’ve advised against always stretching your spine when it’s stiff based on spine anatomy and seeing the results in the clinic.

Some excellent recent research refutes the correlation to feeling tight, and actually having tightness in the back. Check it out here.

The Research

Stanton and colleagues studies a group of people with and without symptoms of back tightness. Specifically, each subject rated their degree of stiffness on a 0-100 scale.Then they objectively measured the actual stiffness of their spine by using a standard force to their vertebrae and measuring displacement.

They found that there was no correlation to perceived stiffness and actual stiffness.

The same researchers also found that those with perceived stiffness were also more sensitive to applied force. Also, when given an auditory cue while the force was applied, it altered their perception of how much force was applied. For example, when an increasingly high creaking noise was played while applying a force, those with back stiffness overestimated the perceived amount of force applied. In contrast, when a decreasingly loud creaking noise was played while applying force, they underestimated the force being applied.

This corroborates with other finding suggesting that pain is a multi-sensory experience.

So what does this all mean?

There are several key things these findings tell us we should do, or not do.

First, just because you feel tight, it doesn’t mean that you really are tight. Rather, it might mean that your tissues are sensitive and protecting.

Ok, so what?

Don’t go out of your way to go crazy things to “lengthen”, “stretching”, or “mobilize” your back. Because if you do, you might be, at best, barking up the wrong tree. There’s probably something else going on that you should turn your attention to:

  • poor ergonomics (sitting too long, staying in awkward positions for too long),
  • poor endurance (ie doing tasks that you’re  poorly conditioned for, like gardening all day when you are poorly trained for that), or
  • poor motor control (lacking the coordination to place your spine in positions to optimally distribute and produce force).
  • hyper sensitive neural tissues; central or peripheral.

At worst, by stretching, manipulating, and mobilizing by chasing the stretch, you could be further irritating vulnerable tissues or further lengthening loose tissues. For example, the discs, ligaments, nerves, and facet joints of the spine are far less tolerant to stress than muscles, especially when irritated. Attempts focused on mobilizing tissues that aren’t really stiff may be making things worse. Surprisingly sometimes  the negative symptoms people feel when stretching are falsely justified as necessary to “loosen” the “stiff” muscles or joints. (more on this below).

But it feels so good to stretch!

Just because it feels better doesn’t always mean you should do it. Scratching an itch may feel better now, but doing so increases the histamine response so it keeps itching, and picking the scab delays healing.

Stretching your back certainly isn’t always bad. In fact, in many cases it can help greatly. However, it doesn’t need to be done aggressively or for prolonged periods. In cases when stretching seems to help back issues, it’s not always because it is reducing stiffness. Rather, it can help because it may provide the brain with positive afferents that alter pain reception and inhibit guarding, all things that help some types of back pain. This is also a mechanism by which joint manipulation works. This explains how joint manipulation can reduce pain in some cases, even though it is proven NOT to “realign” any joints.

Also, in the case of mobilization, it can improve water concentration in the discs, associated with improved health, pain reduction, and function of the spine.

The key is to determine whether your spine is truly stiff or not, which is best done with both an examination and proper history, preferably by someone who isn’t biased with a certain treatment approach (ie chiros that manipulate everyone, surgeons that advocate surgery for most before therapy, pain specialist that inject everyone). If it truly is stiff, then apply gentile mobilization, manipulation, and stretching techniques. And if you have to do this all the time, it probably isn’t working.


I’m alarmed by how many people with back issues, and even more so clinicians, focus on just treating symptoms. What is the point if you don’t find the cause? They just keep coming back.

Improving symptoms are important, but keeping them from returning is even more important. And that means looking for the cause. That should be the goal.

Common causes

The primary causes of most back pain are:

    Prolonged sitting, prolonged any position, doing tasks that you aren’t properly conditioned for.

In people with known back issues, the following are the most common causes I see based on my clinical experience and research.

    reaching, bending and twisting repeatedly beyond your base of support, especially with heavy loads, poor torso muscle endurance, poor lumbopelvic motor control, poor hip mobility, poor general strength and fitness, poor self-management strategies (pain reduction, stress reduction), and fear avoidance/pain catastrophication

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