Back pain in certain positions is a very common patient complaint, citing exacerbated symptoms when the body is standing, sitting or reclining. Positional back pain is the general rule, rather than the exception, with most patients demonstrating evidence of heightened pain in particular anatomical postures. Strangely, in virtually all of these cases, scientific evidence for why this occurs is definitively lacking, although in some instances, there are logical reasons to explain the increased symptomatic expression.
When discussing positional back pain, one needs to consider all of the factors that can lead to posture-related symptomology. This includes factoring in anatomical contributors, conditioning contributors and mindbody contributors. We will look at all three factors in this essay, so patients can enjoy a rare complete view of this topic, instead of the simplistic purely bodily perspective often provided by caregivers.
This dialog examines positional back and neck pain from a comprehensive point of view.
Standing is a known torture for many back pain patients. Standing is certainly the most physically taxing posture to maintain for an extended time frame, but humans are capable of standing for very long periods without enduring any ill effects. Not surprisingly, standing for work-related activities is cited as being more stressful than standing in pleasurable circumstances.
Strangely, many patients who can not stand in one place for long actually report improved symptoms when walking. This is seemingly illogical in many symptom sets, but is still one of the main factors common to approximately three quarters of patients who report standing-related back pain.
Standing is cited as a contributory factor by more obese patients and elderly patients, which is not surprising. Overweight people suffer far more stress on the body when having to hold up their entire mass. Meanwhile, elderly people might suffer muscular deficiencies and degenerative conditions that may also be sensitive to weight-bearing activities.
Central spinal stenosis is certainly one of the main anatomical causes of pain suffered when standing. This is particularly true for patients who suffer from lumbar stenosis, since the standing position further decreases the available patency of the central canal space. Sciatica might also be more painful when the patients is standing, since the legs are most often affected and seem to demonstrate worse symptoms when used in physical tasks in many patient profiles. Other diagnoses that might enjoy a purely physical basis to explain worsened symptoms when standing include lower back muscle pain, sacroiliac joint pain, hip pain and knee pain.
Sitting is almost universally cited as being a worsening factor for lower back pain patients, with the exception being patients who suffer from lumbar spinal stenosis. However, sitting is also deemed responsible for increasing symptoms in middle back, upper back and neck pain patients as well, with a majority of patients reporting that sitting indeed escalates pain.
Some patients report that long periods of sitting makes them stiff and exacerbates their back or neck pain. Other patients cite pain immediately upon sitting and this pain is often worse in particular seated activities, such as driving or working. Sitting is most often reported as an exacerbating factor to active, athletic people and people who do not like to be sedentary.
Sitting might provide some anatomical basis to increase pain in some patients, since it does change the shape of the spine and this adjustment might compound structural issues such as spondylolisthesis, scoliosis, lordosis or kyphosis. Sitting might also increase stress on compressed nerves or may worsen chemical radiculitis concerns.
Reclining seems to be the least logical position for pain to occur, since the body is meant to derive comfort and rest from this natural passive posture. However, many patients suffer escalated pain complaints when reclining generally or in specific positions. Some feel the symptoms increase when they lie down to relax, while others can recline comfortably in some positions, but have pain in other positions. Reports of sleep position problems are extremely common among all manner of back pain patients who suffer from a staggering range of diagnoses.
Some patients can not lie on their backs, while others can not lie on their sides or stomachs. Some patients must recline with pillows to support them, with typical placements being under the knees, between the knees, under the lower back or under the arm. Many patients report heightened symptomatic activity when sleeping on an unfamiliar surface or with particular types of pillows. Some patients report better results when not using any pillow under the head whatsoever.
There might be some highly specific basis which induces pain in certain reclining positions. However, it seems unlikely that most cases of reclined positional back or neck pain are anatomically-motivated.
As mentioned in the opening paragraph, there are three main contributors that can cause positional back pain. The first in related to the body, while the second and third are related to the mind. Purely anatomical factors for positional pain have been documented in the three sections above, so in this final section, we will focus on the remaining 2 possible causes and contributors to posture-related pain syndromes.
Conditioning, also known as programming, is a universal human phenomenon wherein patients experience pain coincidentally when a person happens to be in a particular position. They associate the pain with the activity, often illogically, and therefore come to expect pain when positioned in the same manner in the future. Conditioning can also occur in combination with a psychosomatic pain condition when the nocebo effect makes a person believe they will experience pain from a specific activity and so it indeed occurs. The pain is not actually generated from the activity itself, but merely from the psychoemotional expectation of pain that is linked to the activity in question.
The third and closely related cause of positional pain is the mindbody interaction that can create pain through psychogenic or psychosomatic mechanisms. Patients rarely consider what is on their conscious mind when pain strikes. Instead, they tend to focus on the physical state of their body when the flare-up occurs. Virtually no patient will go one step further and consider how repressed subconscious and unconscious sensitivities in their mind might be stirred up by conscious thoughts, inciting the need for pain to assist the repression process. Both of these scenarios are defense mechanisms enacted by the mind to create pain in the body in order to hide uncomfortable and frightening emotions. These are the ways the mind and body interact and this idea forms the basis of mindbody medicine and its preferred treatment, knowledge therapy.
We always recommend looking at positional pain complaints objectively and considering all three possible contributors to the symptomatic expression. Failing to do so will likely leave considerable room for diagnostic error to occur and will eventually result in the type of unsatisfying treatment outcome that has become the norm in the back and neck pain industry.