Myth Busting: Is My Back Pain Caused by Bad Posture?

Is Bad Posture the Cause of My Back Pain?

Many people with back pain are of the belief that bad posture plays a significant role in their pain. Some clinicians spend a considerable amount of time analysing posture and attempting to link this to back pain.

So, is there any evidence for a link between bad posture and back pain?

There are two questions we should address in trying to answer this:

  1. Does the Evidence Show a Link Between Poor Posture & Pain?
  2. Is there a Difference in Posture Between Individuals with & without Back Pain?

Is My Back Pain Caused by Bad Posture? Naas Physio & Chiropractor Clinic

Laird RA, Gilbert J, Kent P, Keating JL. Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014;15:229. Published 2014 Jul 10. doi:10.1186/1471-2474-15-229

This research review incorporated 8 different studies.
In summarising their findings, the authors found that, on average, people with low back pain had no difference in low back posture compared to those without low back pain.

 

Swain CTV, Pan F, Owen PJ, Schmidt H, Belavy DL. No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. J Biomech. 2020;102:109312. doi:10.1016/j.jbiomech.2019.08.006

Here, the authors found that some studies find a link between posture and back pain whereas others do not.
When only the higher quality studies are included then they could not find any consistent evidence for a link between back posture or physical activity and low back pain.

Can Bad Posture Cause of My Neck Pain?

Karen V Richards, D Clin Physio, M Manip Ther, Darren J Beales, PhD, M Manip Ther, Anne L Smith, PhD, M Biostatistics, Peter B O’Sullivan, PhD, Grad Dip Manip Ther, Leon M Straker, PhD B App Sc (Physio), Is Neck Posture Subgroup in Late Adolescence a Risk Factor for Persistent Neck Pain in Young Adults? A Prospective Study, Physical Therapy, Volume 101, Issue 3, March 2021, pzab007, https://doi.org/10.1093/ptj/pzab007

 

In this study with 686 participants, the authors found that sitting neck posture at 17 was not a risk factor for persistent neck pain at 22 years of age in males.

Interestingly, in females, they found that more relaxed postures (slumped and intermediate postures) were protective of neck pain compared with upright posture.

The authors concluded that ‘the practice of generic public health messages to sit up straight to prevent neck pain needs rethinking.’

Is My Nack Pain Caused by Bad Posture: Naas Physio and Chiropractor

Is there a link between Poor Posture and Neck Pain?

Ariëns GA, Bongers PM, Douwes M, et al. Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occup Environ Med. 2001;58(3):200-207. doi:10.1136/oem.58.3.200

This study followed a group of 1334 workers for a period of 3 years across 34 companies.

Work related physical load was assessed via video recordings of neck flexion, neck rotation, and sitting posture. Neck pain was assessed by a questionnaire.

A significant positive relation was found between the percentage of the working time in a sitting position and neck pain, implying an increased risk of neck pain for workers who were sitting for more than 95% of the working time.’

A trend for a positive relationship between neck flexion and neck pain was found, suggesting an increased risk of neck pain for people working with the neck at a minimum of 20° of flexion for more than 70% of the working time. No clear relation was found between neck rotation and neck pain.

‘Sitting at work for more than 95% of the working time seems to be a risk factor for neck pain and there is a trend for a positive relation between neck flexion and neck pain. No clear relation was found between neck rotation and neck pain.’

 

Do Movement Breaks Reduce the Incidence of Back Pain?

Waongenngarm P, Areerak K, Janwantanakul P. The effects of breaks on low back pain, discomfort, and work productivity in office workers: A systematic review of randomized and non-randomized controlled trials. Appl Ergon. 2018;68:230-239. doi:10.1016/j.apergo.2017.12.003

The authors in this study evaluated the effectiveness of active breaks on low back pain and productivity in office workers. They referred to all publications released over a 36 year period. 

The length of both working time and break times were highly variable between studies and therefore difficult to compare.

The authors concluded that ‘…..active breaks with postural change may be effective in reducing pain in workers with acute low back pain and to prevent discomfort in healthy subjects.’

The evidence also suggested that the use of breaks had no detrimental effect on work productivity.

 

Do Sit-To-Stand Desks Help to Reduce Back Pain?

Agarwal S, Steinmaus C, Harris-Adamson C. Sit-stand workstations and impact on low back discomfort: a systematic review and meta-analysis. Ergonomics. 2018;61(4):538-552. doi:10.1080/00140139.2017.1402960

Here, they identified eight relevant studies & concluded that sit-stand workstations, by leading to changes in posture may reduce low back pain among workers.
 


De Carvalho D, Greene R, Swab M, Godwin M. Does objectively measured prolonged standing for desk work result in lower ratings of perceived low back pain than sitting? A systematic review and meta-analysis. Work. 2020;67(2):431-440. doi:10.3233/WOR-203292

Prolonged sitting has been shown to induce transient low back pain. Height adjustable office desks now present the opportunity to replace sitting with standing in the workplace. Since standing has also been associated with back pain, this may not be an advisable alternative.

The results of three studies were pooled & the authors stated that:

prolonged standing postures during desk work did not induce significantly less perceived low back pain compared to seated postures.’

They concluded that ‘It appears that replacing seated desk work postures with standing for prolonged periods of time would not be recommended.’

My summary:
So, the evidence seems to be mixed when it comes to sitting or standing in terms of back pain prevention. Prolonged sitting, however, has several negative influences in terms of health. For example, prolonged sitting is associated with negative metabolic changes which can predispose to weight gain, diabetes and cardiovascular disease.

It appears that ‘active breaks’, where you are moving or performing exercise may be optimal for decreasing back pain incidence and improving overall health

 

 

Do Physical Jobs Increase the Risk of Back Pain?

Khan MI, Bath B, Boden C, Adebayo O, Trask C. The association between awkward working posture and low back disorders in farmers: a systematic review. J Agromedicine. 2019;24(1):74-89. doi:10.1080/1059924X.2018.1538918

Although studies of the general population have shown an association between low back disorders and awkward working posture, farmers have unique work context and exposures that may modify this relationship.

Nine studies were included in this review & they all used self-reported measures.

Despite the diversity, the weight of evidence supported a relationship between awkward posture and low back disorders.

My summary:
This particular study, using self-reports of poor posture, would be deemed very poor quality.
The authors concluded there may be a link between extremes of posture, as might occur in farming or heavy labour, but it is hard to be definitive from this study.

 

Roffey DM, Wai EK, Bishop P, Kwon BK, Dagenais S. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. Spine J. 2010;10(1):89-99. doi:10.1016/j.spinee.2009.09.003

A systematic review was performed to identify a potential link between awkward occupational postures and LBP. Eight high-quality studies reported on awkward occupational postures and LBP.

The authors found ‘no association between awkward occupational postures and LBP, with only two studies demonstrating significant associations compared with six studies reported mainly nonsignificant associations.’

‘It is therefore unlikely that awkward occupational postures are independently causative of LBP in the populations of workers studied.’

 

Coenen P, Gouttebarge V, van der Burght AS, et al. The effect of lifting during work on low back pain: a health impact assessment based on a meta-analysis. Occup Environ Med. 2014;71(12):871-877. doi:10.1136/oemed-2014-102346

Lifting at work is considered an important risk factor for low back pain (LBP). However, contradictory findings have been reported, partly because frequency, duration and intensity (ie, the weight of the load) of lifting have not been systematically considered.

The aims of this study were: to assess the effect of lifting during work (quantified in duration, frequency or intensity) on the incidence of low back pain (LBP) and to quantify the impact of these relationships on the occurrence of LBP in occupational populations exposed to lifting.

Eight studies were included.

‘..we estimated that lifting loads over 25 kg and lifting at a frequency of over 25 lifts/day will increase the annual incidence of LBP by 4.32% and 3.50%, respectively, compared to the incidence of not being exposed to lifting.’ Intensity and frequency of lifting significantly predict the occurrence of LBP.

 

What Causes Back Pain in Cyclists?

Streisfeld GM, Bartoszek C, Creran E, Inge B, McShane MD, Johnston T. Relationship Between Body Positioning, Muscle Activity, and Spinal Kinematics in Cyclists With and Without Low Back Pain: A Systematic Review. Sports Health. 2017;9(1):75-79. doi:10.1177/1941738116676260

Low back pain is reported by more than half of cyclists. The causes of back pain in this group is not clearly understood.

Eight studies were included in this review.

Core muscle activation imbalances, back extensor endurance deficits, and increased lumbar flexion while cycling were found to be present in cyclists with low back pain.

 

My Summary of the Research:

  • There is no clear link between poor posture and neck or back pain
  • Prolonged sitting seems to be linked with back pain as opposed to the posture of sitting or type of chair
  • Taking regular active breaks may help decrease back pain
  • The evidence for using standing desks in terms of back pain is in its infancy but is unclear at present
  • Awkward postures being assumed regularly during work does not show a clear link with back pain.
  • Heavy manual labour seems to demonstrate an associated with an increase in back pain

 

It might be a case that, for some people, posture is a significant cause of their back pain, but because there are several factors that can cause pain, it might need to be present alongside other characteristics. When dealing with studies involving larger groups, this may not show up as statistically significant.

In other words: always keep an open mind!!

Return to home page: https://www.physioclinic.ie/chiropractor-naas/

What is the best treatment for achilles tendon pain?

What Causes Achilles Tendon Pain?

Achilles tendon pain is common in runners and those who have recently increased their exercise duration. The pain of an achilles tendon injury often appears at the start of a run and then eases out as the run continues. because the pain improves by continuing the run, people often assume that continuing to run is harmless, or might even be helpful in alleviating the pain. Unfortunately, continuing to train through the pain frequently gives rise to more severe and intractable pain. The longer the pain is present then the longer it takes to heal.

What is the best treatment for achilles tendon pain?

Does Running Technique Impact on Achilles Tendon Pain?

A biomechanical running technique assessment is a vital component of assessing an achilles injury. There are two types of foot strike that are generally discussed in the literature: a forefoot and a rearfoot strike. A forefoot strike is where the runner lands on the ball of the foot with the heel off the ground. A rearfoot strike is where the runner hits the ground with the heel first and follows through with the forefoot

How does Foot Strike Impact Achilles Loading?

The way an athlete strikes the ground while running will have a big impact on the overall loading of the knee and ankle joints.  A forefoot strike, for example,  is associated with higher loading of the achilles tendon. Excessive loading of the achilles tendon is the main stimulus for injury and therefore modifying the loading overall training load is vital to recovery. A cycle of tendon overload, followed by inadequate repair forms the basis for achilles tendon pain. Recovery from injury will prove challenging unless improvements in running technique are implemented. 

“Fallen arches” tends to be one of the main reasons that patients give for their achilles pain. The evidence for foot pronation as a cause of achilles tendon pain is weak, despite patients consistently mentioning this as the source of their pain.  

Other running technique factors such as overstriding has been linked to heel and knee pain. This is where the runner, in an attempt to take a long stride, stikes the ground with their heel and transfers significant ground reaction forces up through the leg.

Some simple tips for improving running technique include:

  • Increasing your step rate (research on olympic athletes suggest that a step rate of 180 per minute was optimal for reducing impact forces)
  • Decreasing stride length
  • Striking the ground with a flat foot directly under your hip

What is the best treatment for achilles tendon pain blog

Walking Re-Education in Achilles Tendonitis Management

Any negative thoughts regarding pain can give rise to limping. This may be rationalised as “taking pressure off my heel”. Continuing with this movement pattern can give rise to wasting of the muscles and tendon and can prevent recovery if the person does not relearn how to walk properly again.

In terms of running technique, if you have been largely injury free then you are best to maintain your current foot strike pattern. Messing with your running technique can give rise to unnecessary injury. If you really feel the need to change your technique then it should be done on a very gradual basis.

Research on Exercise Rehabilitation for Achilles Tendinitis

There has been a lot of talk about eccentric resistance training for managing achilles tendon injury. Eccentrics involve slowly lowering the heel from a raised position to create tension on the achilles tendon.

A recent randomised controlled trial compared the effectiveness of 12 weeks of eccentric training (ECC) versus heavy slow resistance training (HSR) among 58 patients with achilles tendinopathy of greater than 3 months.

The authors concluded that both eccentric and regular resistance training were equally effective in the management of achilles tendinopathy

How effective is Acupuncture for Achilles Tendinopathy?

Recent research published in the journal ‘Physiotherapy Practice and Research’ examined the effect of acupuncture in treating achilles pain in  twenty-two patients. The participants were randomised to receive either acupuncture or the control sham acupuncture treatment

The authors concluded that an acupuncture protocol could be used as a second line treatment alongside a physiotherapy guided exercise rehabilitation programme.

This corroborates the findings of Zhang et al. (2012) who reported significant functional improvement and decreases in heel pain in individuals undergoing acupuncture

References:

Zhang BM, Zhong LW, Xu SW, Jiang HR, Shen J. Acupuncture for chronic Achilles tendnopathy: a randomized controlled study. Chin J Integr Med. 2013;19(12):900-904. doi:10.1007/s11655-012-1218-4. https://pubmed.ncbi.nlm.nih.gov/23263998/

Kishmishian, Berj, Richards, Jim, and Selfe, James. ‘A Randomised Feasibility Study Using an Acupuncture Protocol to the Achilles Tendon in Achilles Tendinopathy’. 1 Jan. 2019 : 59 – 67.

For further information on achilles tendon pain visit our achilles page at: https://www.physioclinic.ie/conditions/achilles-tendon-injury/

Do Weight Lifters Get More Back Pain than those Who Don’t Lift Weights

Do Weight Lifters Get More Back Pain than those Who Don’t Lift Weights?

What prompted this blog was a discussion with a patient about whether they should continue lifting weights after hurting their back in the gym. In this case the pain came on while squatting; however, another commonly reported cause of back pain is deadlifting.

Do weightlifters get more injuries by Naas Physio & Chiropractor

Firstly, I think it is important to get an overview of the overall injury rates in weightlifters in comparison to athletes in other sports. The evidence seems to suggest that injury rates in weightlifters are similar to other non-contact sports also requiring strength/power, but low compared to contact sports. The most commonly injured regions from weightlifting are the spine, shoulders & knees (Aasa et al. 2017; Siewe et al. 2011).

The next question of interest is:

  • Does weight lifting create structural changes in the spine i.e. arthritis or disc damage?
    &
  • Do these anatomical changes correlate with pain?

One study attempted to address these queries by analysing 12 adolescent weightlifters (6 boys & 6 girls) over a period of 2 years. Based on annual MRI scans, the researchers reported finding abnormal findings on MRI examinations reflective of early stage degenerative changes. All bar one of the participants demonstrated disc bulges on the scan. The authors reported that the weightlifters displayed irreversible structural changes in the spinal joints. Significantly though, these changes present on the MRI scans did no correlate in any way with actual back pain or other symptoms. (Shimozaki et al. 2018).

Of course, this phenomenon of changes on MRI scans showing very little or no correlation with pain is well recognised by the scientific community.

This is yet another example of how ineffective MRI scans of the spine are in identifying the source of back pain!

Coming back to our original case of pain after lifting weights: in this case, the patient reported that he had stopped squatting because of back pain. So the important question is this: is avoidance the best approach or should you challenge yourself to work through the offending exercise?

An analogy I often like to use in a case like this is that of an athlete who tears their hamstring while running. Should that person then avoid running in the future. After all, if they stop running, they are unlikely to tear their hamstring again!

Another common example I hear is that of someone injuring their back while performing a menial task like lifting a bag. So, should the woman who hurts their back while lifting their handbag never perform this lift again? It wouldn’t be particularly logical would it?

Should I Avoid Lifting if I Have Back Pain?

Is it different when it comes to lifting very heavy weights you might ask. Should a weight lifter avoid the exercise or start using a belt to ‘support’ their back while lifting heavy?

Research into the use of back belts shows no benefit in terms of back pain prevention. One study actually suggested an increase in back injury rate when powerlifters utilised a weight belt so we can safely rule this out as a solution to your problem.

Over the years, I have come across people who repeatedly injure themselves while lifting heavy weights; however, this is reasonably rare, and most people should be able to continue with the offending exercise without excessive risk. For some people, either due to technique issues or negative structural changes in the joints from years of lifting weights, they may choose to avoid the activity altogether. Generally speaking, however, the more we condition ourselves to an activity the lower our risk of injury when performing that activity in the future.

Does weightlifting increase the risk of back pain by Naas Physio & Chiropractor

Should I Continue Deadlifting if I Developed Back Pain?

Historically I have encountered 3 types of people who have injured their backs while deadlifting:

  • People who are new to deadlifting
  • Those setting up for a record lift, either in terms of weight or volume
  • Those who have a chronically poor lifting technique. These individuals have often trained for years and will get intermittent injuries to the back once or twice per year. Many times, this type of person is an experienced lifter who has a decent lifting technique with moderate weight but this breaks down when they ‘overreach’ on very heavy lifts which causes them pain.

Generally speaking, the first two categories should be able to continue with the offending exercise in a graduated form while paying attention to technique and avoiding significant increases in the weight being lifted.

The long-term lifter who has repeatedly hurt themselves while lifting may get to a point where the risk-to-reward ratio is no longer in their favour. In this case, I will often ask the client: do you need to do this exercise? Is it vital for your sporting performance? In most cases the answer is no, and so it is a relatively easy decision to omit the offending exercise from your routine.  

In many cases, modifying the exercise or even coming up with a similar movement but with lower load exposure, such as would happen with a single-leg or single-leg dominant lift is the answer for that athlete.

 

Does Weightlifting or Exercise Help Prevent Reoccurence of Back Pain?

Study Title: Fernández-Rodríguez R, Álvarez-Bueno C, Cavero-Redondo I, Torres-Costoso A, Pozuelo-Carrascosa DP, Reina-Gutiérrez S, Pascual-Morena C, Martínez-Vizcaíno V. Best Exercise Options for Reducing Pain and Disability in Adults With Chronic Low Back Pain: Pilates, Strength, Core-Based, and Mind-Body. A Network Meta-analysis. J Orthop Sports Phys Ther. 2022 Aug;52(8):505-521. doi: 10.2519/jospt.2022.10671. Epub 2022 Jun 19. PMID: 35722759.

This research analysis attempted to identify the best exercise options for reducing pain & disability in adults with chronic back pain. 118 trials involving almost 9710 participants were included.

Most forms of exercise were found to be beneficial for improving pain and disability. Interestingly, stretching exercises were found to be ineffective for reducing pain.

Study Title: Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H, Bowe SJ, Belavy DL. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med. 2020 Nov;54(21):1279-1287. doi: 10.1136/bjsports-2019-100886. Epub 2019 Oct 30. PMID: 31666220; PMCID: PMC7588406.

This research team utilised records from 89 studies involving over 5,500 patients.

From pooling the data they concluded that resistance & stabilisation exercises rated highest for physical function, pilates ranked highest for pain reduction, & resistance & aerobic exercise ranked highest for mental health; however, the quality of the synthesised evidence was low according to the authors.

 

Study Title: Nambi G, Abdelbasset WK, Alqahtani BA, Alrawaili SM, Abodonya AM, Saleh AK. Isokinetic back training is more effective than core stabilization training on pain intensity and sports performances in football players with chronic low back pain: A randomized controlled trial. Medicine (Baltimore). 2020 May 22;99(21):e20418. doi: 10.1097/MD.0000000000020418. PMID: 32481345; PMCID: PMC7249999.

Sixty university football players with chronic low back pain were divided into 3 groups who performed their respective exercise routines over a 4 week period.

  • Isokinetic group (IKT; n = 20) (Isokinetic machines apply resistance that adapt to your capacity through the movement. This would be most closely aligned to using free-weights in a real-world scenario)
  • Core stabilization group (CST; n = 20),
  • A control group (n = 20)

The clinical outcome measures used included pain intensity as well as sports performances (40 m sprint, 4 × 5 m sprint, submaximal shuttle running, counter movement jump, and squat jump) scores were measured at baseline, after 4 weeks, 8 weeks, and 3 months.

After four weeks of training the isokinetic training group showed a greater reduction in pain intensity versus the control group. The sports performance variables mentioned also showed a significant improvement in the isokinetic group when compared to the other 2 groups.

 

Study Title: Grooten WJA, Boström C, Dedering Å, Halvorsen M, Kuster RP, Nilsson-Wikmar L, Olsson CB, Rovner G, Tseli E, Rasmussen-Barr E. Summarizing the effects of different exercise types in chronic low back pain – a systematic review of systematic reviews. BMC Musculoskelet Disord. 2022 Aug 22;23(1):801. doi: 10.1186/s12891-022-05722-x. PMID: 35996124; PMCID: PMC9394044.

The findings from this research, incorporated 45 studies, shows that the effect of various exercise types, including resistance training, TCE, MCE, pilates & yoga, when used to treat pain and disability varies with no major difference between exercise types.

 

Study Title: Fischer SC, Calley DQ, Hollman JH. Effect of an Exercise Program That Includes Deadlifts on Low Back Pain. J Sport Rehabil. 2021 Feb 24;30(4):672-675. doi: 10.1123/jsr.2020-0324. PMID: 33626500.

This study investigated the effectiveness of an exercise programme that includes deadlifts on back pain.

The authors concluded that ‘Exercise programs that include deadlifts can yield improvements in both pain and function for those living with low back pain but were not found to be more beneficial than low load motor control exercises.’

Strength of Recommendation: Level B evidence exists that exercise programs that include deadlifts are a clinically effective option for the treatment of low back pain for both pain scores and functional outcome measures.

 

Study Title: Tataryn N, Simas V, Catterall T, Furness J, Keogh JWL. Posterior-Chain Resistance Training Compared to General Exercise and Walking Programmes for the Treatment of Chronic Low Back Pain in the General Population: A Systematic Review and Meta-Analysis. Sports Med Open. 2021 Mar 8;7(1):17. doi: 10.1186/s40798-021-00306-w. PMID: 33683497; PMCID: PMC7940464.

This research compared exercise programmes that emphasised the muscle groupings of the lower back, glutes & hamstrings (collectively referred to as the ‘posterior chain’).

Eight articles with a total of 408 participants were included.

The authors concluded that their results indicated that 12-16 weeks of posterior chain resistance training had a significantly greater effect than general exercise on back pain & disability.yh

No differences in the number of adverse events were reported between both groups.

 

Study Title: Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006 Mar 14;174(6):801-9. doi: 10.1503/cmaj.051351. PMID: 16534088; PMCID: PMC1402378.

This study reviewing all the available research (called a systematic review) came to the conclusion that resistance training was superior to general exercise over 12 to 16 weeks when treating individuals with chronic back pain.

References:

Aasa U, Svartholm I, Andersson F, Berglund L. Injuries among weightlifters and powerlifters: a systematic review. Br J Sports Med. 2017 Feb;51(4):211-219. doi: 10.1136/bjsports-2016-096037. Epub 2016 Oct 4. PMID: 27707741.

Fernández-Rodríguez R, Álvarez-Bueno C, Cavero-Redondo I, Torres-Costoso A, Pozuelo-Carrascosa DP, Reina-Gutiérrez S, Pascual-Morena C, Martínez-Vizcaíno V. Best Exercise Options for Reducing Pain and Disability in Adults With Chronic Low Back Pain: Pilates, Strength, Core-Based, and Mind-Body. A Network Meta-analysis. J Orthop Sports Phys Ther. 2022 Aug;52(8):505-521. doi: 10.2519/jospt.2022.10671. Epub 2022 Jun 19. PMID: 35722759.

Grooten WJA, Boström C, Dedering Å, Halvorsen M, Kuster RP, Nilsson-Wikmar L, Olsson CB, Rovner G, Tseli E, Rasmussen-Barr E. Summarizing the effects of different exercise types in chronic low back pain – a systematic review of systematic reviews. BMC Musculoskelet Disord. 2022 Aug 22;23(1):801. doi: 10.1186/s12891-022-05722-x. PMID: 35996124; PMCID: PMC9394044.

Nambi G, Abdelbasset WK, Alqahtani BA, Alrawaili SM, Abodonya AM, Saleh AK. Isokinetic back training is more effective than core stabilization training on pain intensity and sports performances in football players with chronic low back pain: A randomized controlled trial. Medicine (Baltimore). 2020 May 22;99(21):e20418. doi: 10.1097/MD.0000000000020418. PMID: 32481345; PMCID: PMC7249999.

Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H, Bowe SJ, Belavy DL. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med. 2020 Nov;54(21):1279-1287. doi: 10.1136/bjsports-2019-100886. Epub 2019 Oct 30. PMID: 31666220; PMCID: PMC7588406.

Shimozaki K, Nakase J, Yoshioka K, Takata Y, Asai K, Kitaoka K, Tsuchiya H. Incidence rates and characteristics of abnormal lumbar findings and low back pain in child and adolescent weightlifter: A prospective three-year cohort study. PLoS One. 2018 Oct 29;13(10):e0206125. doi: 10.1371/journal.pone.0206125. PMID: 30372456; PMCID: PMC6205614.

Siewe J, Rudat J, Röllinghoff M, Schlegel UJ, Eysel P, Michael JW. Injuries and overuse syndromes in powerlifting. Int J Sports Med. 2011 Sep;32(9):703-11. doi: 10.1055/s-0031-1277207. Epub 2011 May 17. PMID: 21590644. https://pubmed.ncbi.nlm.nih.gov/21590644/

Tataryn N, Simas V, Catterall T, Furness J, Keogh JWL. Posterior-Chain Resistance Training Compared to General Exercise and Walking Programmes for the Treatment of Chronic Low Back Pain in the General Population: A Systematic Review and Meta-Analysis. Sports Med Open. 2021 Mar 8;7(1):17. doi: 10.1186/s40798-021-00306-w. PMID: 33683497; PMCID: PMC7940464. https://pubmed.ncbi.nlm.nih.gov/33683497/

Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006 Mar 14;174(6):801-9. doi: 10.1503/cmaj.051351. PMID: 16534088; PMCID: PMC1402378. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1402378/