Exploring Sit to Stand Workstations

Compliments of Horacio Salinas

 

I’ve been following  the growing research on the effects of the posture of sitting, and more extensively, sit to stand workstations (STSWS).   Of course, part of this path started by listening to my own patients’ complaints of musculoskeletal issues. Most of these patients spend hours seated at a desk, with few breaks to stand and move around. My advice over the years for occupational (seated) dysfunctions has always been to stand at least every fifteen minutes during the work day, and that simple advice had a dramatic impact on common complaints. Yet for many, this advice for better health had a consequence: less productivity.  (Which is why Google employees use STSWS.)  So is sitting detrimental to our overall health?  And do STSWS help improve our health?

A very interesting study from Cornell University in 2004 (yes, old, but interesting) on height-adjustable workstations concluded that “alternating between a sitting and standing posture at work appears to benefit health and productivity” and “results agree with previous research demonstrating beneficial effects of using height-adjustable worksurfaces.” That was 2004, and since then, especially in the last few years, more extensive studies appeared with a focus on what sitting does to our overall health.

A large (and eye opening) study published in the American Journal of Epidemiology in 2010 (Leisure Time Spent Sitting in Relation to Total Mortality in a Prospective Cohort of US Adults), focused on the obesity epidemic and how long periods of sitting affect overall mortality rates:

“The time spent sitting was independently associated with total mortality, regardless of physical activity level.”

Regardless of physical activity.  Scary.  And:

“After adjustment for smoking, body mass index, and other factors, time spent sitting (
6 vs. <3 hours/day) was associated with mortality in both women (relative risk ¼ 1.34, 95% confidence interval (CI): 1.25, 1.44) and men (relative risk ¼ 1.17, 95% CI: 1.11, 1.24).”

If the results of this study don’t get you off your chair, let me continue.

The New York Times published this piece in 2011, which included activity and obesity studies by Dr. James Levine, a researcher at the Mayo Clinic in Rochester, Minn, and cited the American Journal of Epidemiology study mentioned in the previous paragraph:

“Over a lifetime, the unhealthful effects of sitting add up. Alpa Patel, an epidemiologist at the American Cancer Society, tracked the health of 123,000 Americans between 1992 and 2006. The men in the study who spent six hours or more per day of their leisure time sitting had an overall death rate that was about 20 percent higher than the men who sat for three hours or less. The death rate for women who sat for more than six hours a day was about 40 percent higher. Patel estimates that on average, people who sit too much shave a few years off of their lives.“

Wow. Pretty convincing stuff.  But perhaps more intriguing in the New York Times piece is Dr. Levine’s mention of movement, and how it correlates to the mortality rate.  In layman’s terms, moving more often, even while sitting, improves overall metabolic and muscular health. This is a concept I’ve long promoted; we move or we die.  And I love his quote at the end:

“Go into cubeland in a tightly controlled corporate environment and you immediately sense that there is a malaise about being tied behind a computer screen seated all day,” he said. “The soul of the nation is sapped, and now it’s time for the soul of the nation to rise.” 

From a bio-mechanical perspective, standing, just like sitting, has obvious negative connotations to gravity.  Standing postures are often not ideal in most people.  That is, the person might have a kyphotic posture, or varus/valgus hips and knees.  If a patient with poor standing posture decides to purchase a STSWS, she has to consider the standing posture, and its affect on the body.  She may not be able to stand for long periods, and shorter intervals of both standing and sitting might be better.  Yet given the research, even those with poor standing postures would seem to benefit in having a workstation that allowed a convenient way to stand and continue working.

I certainly wanted to find out if I could benefit from a STSWS, so I purchased one.  Given the amount of time I sit writing, I figured I was a pretty good candidate.  Although I don’t have chronic dysfunctions that might come from seated postures, I do feel unproductive when sitting for too long.  And yes, my back does complain.  I have replaced my old desk with the new workstation, and have used it for about sixty days.  I begin my day sitting, and when I get fatigued, I push a button to lift my desk to a standing position.  I then work like that, standing, until I feel the need to sit again.  Now, this is not a “plug” for any particular manufacturer of sit to stand desks, but I must say I now recommend this type of setup to many of my patients.  I mention it on my web site and as part of my consulting for patients with sedentary jobs.  As the first study concluded in 2004, I feel the following benefits:

• increased productivity- I get more done
• less muscular strain
• increased concentration
• increased circulation

That said, if you are considering a STSWS, get good advice/assessment on your current posture.  If you have a scoliotic curve or other known issue, a good rehabilitation program will help you maintain a stable standing posture.  And, keep in mind everyone is different; you may not be able to stand for very long, which is fine.

Just push the button and sit for awhile.

Going Barefoot

 

For the past few years, I’ve been following the research on minimalist, or barefoot, running. My interest, and really fascination, in this research is twofold. First, I am a long time runner who used to compete in 5 and 10 kilometer races, but I also have a career in physical rehabilitation, and have worked with hundreds of runners. After seeing a myriad of running-related injuries in my patients, I began to question whether or not shoes may be contributing to these injuries. And I began to wonder if I should try going barefoot to find out.

In December of 2009, the American Academy of Physical Medicine and Rehabilitation published this article on the effect of running shoes on lower joint forces. The results were extremely interesting: “Increased joint torques at the hip, knee, and ankle were observed with running shoes compared with running barefoot. Disproportionately large increases were observed in the hip internal rotation torque and in the knee flexion and knee varus torques. An average 54% increase in the hip internal rotation torque, a 36% increase in knee flexion torque, and a 38% increase in knee varus torque were measured when running in running shoes compared with barefoot.”

Then Daniel Lieberman, professor of Human Evolutionary Biology at Harvard University, published this study in Nature in 2010. It was also a feature on NPR, (which really pushed me over the edge). From NPR: “Lieberman found that runners in shoes usually landed heel-first. Barefoot runners landed farther forward, either on the ball of their foot or somewhere in the middle of the foot, and then the heel came down — much less collisional force.” And I found it intriguing that when people in this study swapped shoes for barefoot running, eventually they adopted the barefoot style bio-mechanically. The reason, according to Lieberman (who runs marathons himself), is it hurts to strike heel-first without shoes (I can verify this, trust me). That is what running shoes were designed to do; lessen the impact of that strike.

In the Nature study, the discussions on impact and foot strike mirrored what had already been confirmed in the American Academy study. For rear foot strike (RFS) runners, “impact transients associated with RFS running are sudden forces with high rates and magnitudes of loading that travel rapidly up the body and thus may contribute to the high incidence of running related injuries.” So common injuries such as plantar fasciitis could be avoided if these impact forces were reduced, right? I’m beginning to believe this, but let me continue.

One of the most incredible and thought-provoking statements Lieberman makes in the Nature study is this:

“Differences between RFS and FFS running make sense from an evolutionary perspective. If endurance running was an important behaviour before the invention of modern shoes, then natural selection is expected to have operated to lower the risk of injury and discomfort when barefoot or in minimal footwear.”

And that paragraph is what made me go out and purchase a pair of Vibram FiveFingers shoes. I wanted to be the Guinea pig in my own study, and if it was all true, perhaps I could help my patients more and improve my running. The Vibram shoes are designed to fit like a glove, and mimic barefoot running, as they consist of only a thin strip of rubber as a sole. After doing careful research, I knew I’d have to prepare my feet and gradually extend my mileage over a period of time. Part of the argument of shod vs. barefoot running is that running shoes have weakened our foot musculature. So I began wearing the Vibrams all the time to help strengthen my intrinsic foot muscles, and ran the beach barefoot at least twice a week.

Now it’s not hard to FFS in these “shoes;” as Lieberman said, it’s natural because it hurts to RFS. Yet as I began to run on pavement, I found myself overcompensating the FFS. (I only discovered this after a one mile run crippled me the next day. My gastrocnemius muscles were so tender I could barely walk.) On my next run I closed my eyes as I ran (good advice from another barefoot runner) and realized what I was doing. I was trying to stay in a plantar flexed position as I ran, overcompensating the FFS. Once I let my body tell me how to run, everything changed. And I mean everything.

In the past 6 months, I’ve progressed to 6-8 miles on pavement. The best way to describe what I feel when I run now is liberated. I feel light, my stride has shortened (a natural result of the FFS), and I often want to keep running because it feels so damn good. Yet there is also a sensory element when I run now that I did not experience when I wore shoes. I feel the ground, every bump, pebble, leaf. And there is something bordering on spiritual in this kinesthetic element; running is an experience now. Physically, my body feels different, both while running and after. I don’t hurt. My neuroma and tarsal issues are gone.

While I will never wear running shoes again, the big question professionally is would I recommend patients to do the same? Yes and no. Anyone who knows me understands I loath braces, wraps and inserts. And they understand I’d rather strengthen foot arches and ankles when treating something like plantar fasciitis (instead of taping and inserts). So I do believe that strengthening the foot musculature could help a lot of people (and for most I mean walking, not running). The problem is getting there. Most people are in such poor stages of chronic inflammation and injury that you cannot expect them to start wearing minimalist shoes to walk in all the time. But I do believe if they are helped with other exercise protocols they can get there.

Should every shoe runner switch to the barefoot style? While most runners have an incredible base of running years behind them, most people do not. People that run occasionally, are overweight, and have legs as thick as linebackers, probably will have a hard time acclimating to the no-shoes style. (Although I do know a few such linebackers that are running in minimalist shoes without injury.) Body type plays a large role in foot bio-mechanics and impact forces, so not everyone should run (there is nothing wrong with walking). What remains clear to me is that everyone could- and really should try – walking in minimalist shoes, and strengthen those muscles that shoes help destroy.

At a recent Sports Medicine symposium I attended in Atlanta, barefoot running came up in a discussion lecture. The speaker was a well known orthopedic surgeon from Emory Healthcare. The question was simple: “What do you think of barefoot running?” The simple answer? “We need to do more research.” While I agree with the doctor, I’m going to slip on my Vibrams and run.

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Tags: barefoot, medicine, running, sports

The Negative Language of Back Pain

“Patient complaints that originate in the musculoskeletal system usually have multiple causes responsible for the total picture.” -Drs. Travell and Simons

“The first treatment is to teach the patient to avoid what harms him.” -Karel Lewit, MD

“He who treats the site of pain is lost.” -Karel Lewit, MD

After seventeen years of running a private rehabilitation clinic, I’ve seen my share of back pain in my patients. It is one of the most common ailments I see, but it is also one of the most misunderstood concepts for the patient, mainly because of the confusing, and often negative, language in the medical field. Patients with back pain – much like pain anywhere in the body- are confused about why it exists: “How did it happen?” “I woke up with this,” are common statements. When the healthcare provider informs them “your back is out,” or “you have stenosis,” and “you have degenerating disks,” the patient assumes the worst ( “I’m degenerating?”). While these physical items might very well exist, and yes, back pain can be related, chances are the patient’s pain has nothing (or very little) to do with them. Yet the patient is told an MRI is “bad” because a disk is herniated (recent studies show that patients with herniations have no pain related to them)₁ . The patient begins to believe he or she is doomed. After an MRI is ordered – and they are processed at an alarming and completely superfluous rate in the United States – _2., the patient is hit with an onslaught of impossible medical jargon.

Does the patient need to spend time listening to the radiologist so she can have a better understanding of the issues? Yes, but the delivery of such information needs to be filtered and converted into more positive and educational bits. Over the years, many MRI reports I’ve read showed a myriad of structural changes (spondylolysis, lumbar stenosis, protruding disks, et al), yet in my own clinical experience most of the patient’s pain was not a result of these physical findings. Yet the MRI places the patient into an anxious mindset for therapy because of these “physical” findings and their foreboding visuals of “it,” the one thing that is the cause of it all. I’ve seen it again and again, the patient in obvious jabbing pain, unable to sit comfortably, pushing the MRI report in front of me exclaiming, “It’s the stenosis.”

The first thing I try to do when a patient brings in an MRI report is help relieve some of the anxiety associated with a “bad” MRI. For any therapy to take place, the clinician must establish a positive mind-set for the patient from the initial evaluation. I do this in part by explaining, in layman’s terms, how soft tissue reacts to stresses of the skeletal system, and how structural changes to the spine often are not the issues causing the back pain. I try, ultimately, to get her mind off that one thing that she believes is the problem. For example, I’ve had many lumbar stenosis patients who do not have every symptom of pseudoclaudication, but have a thoracolumbar muscle region that is completely dysfunctional. Yet most physicians overlook this. (And others, too. At a recent physical therapy symposium I attended, I asked the physical therapist who taught a course on back pain if he ever considered the sacral ligaments and related soft tissue in his manipulations. “No,” he said, “They really are not important.” Huh?)

I also explain to the patient that, while we cannot eliminate the stenosis or structural change, we can focus on releasing the thoracolumbar area to relieve the pain and postural dysfunction. (That’s why massage therapy is so effective for back pain. See the story on NPR.) I have improved pain and quality of movement in my patients on this very premise, and have reproduced this result over and over in patients who thought they were destined for surgery.

So “bad” MRI’s are not necessarily a ticket to debilitation and poor quality of life, and the patient, once she understands this, is in a remarkable position to improve her dysfunction.

Some of the Poor Language of Back Pain

• Your back is not “out.” This is one of the most common phrases I hear both told to and from patients, and it’s understandable why it is used by the patient. The patient may often feel something is “out” when the thorocolumer region is in spasm. If disks are misaligned, research shows they will resolve themselves over time, sometimes with a little self-help. ₁
• You are not “degenerating.” Yes, our bones undergo arthritic changes as we age, which means we need more muscle stability to help protect them, but we are not literally disintegrating. Patients are not damaged but have dysfunction!
• It did not happen over night. While it might seem as though the pain suddenly developed over night, usually this is not the case. Soft tissue dysfunction has a snowballing effect; it develops from a single event that gets worse over time. ₃
• Does the patient really need an MRI? Getting a second opinion is always a good idea. I recently visited a podiatrist to get a mucoid cystremoved from my second toe. He insisted he must order an MRI, even though it is one of the most common cysts that occur on the hands and feet. (I refused and the cyst resolved itself.) Radiological films are always a good start, too.

***

1. Cherkin D, Deyo R, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998;339:1021-9.

2. Magnetic resonance imaging and low back paincare for medicare patients. Baras JD, Baker LC.
Health Aff (Millwood). 2009 Nov-Dec; 28 (6):w1133-40

3. Bogduk N, Twomney L. Clinical Anatomy of the Lumbar Spine. Churchill Livingstone