Author Archives: Dr. Henry Sanford

About Dr. Henry Sanford

As a retired consultant in Orthopaedic (Musculo-skeletal) medicine, I was first trained in Orthopaedic Surgery and changed when working with JH Cyriax at St Thomas' Hospital, London, my old teaching hospital. He is regarded as the 'Father' of the subject. I worked as an Associate Consultant in the Rheumatology department, STH, in private practice in Harley St. and the Cromwell Hospital. I have run courses and lectured in in the UK, USA, Belgium, Germany, Scandinavia.

SITTING SAFELY? HOW WE SIT NOW

Ergonomics of sitting safely.   How we sit now is badly!  The recommended ‘correct’ posture  being almost impossible to maintain, most of us sit in a posture that can be shown to invite spinal breakdown.

The photographs show a group of doctors and physiotherapists who are attending a course on orthopaedics.    Most are sitting slumped with rounded back. This allows the pelvis to tilt backwards and  stretches the posterior ligaments but is not as adverse as sitting bolt upright as currently advised and is nearly impossible to maintain.

WWSN1

 

WWSN.2

The chair seats are parallel to the floor so that an upright posture must entail flexion of the hips at a right angle.   The lumbar lordosis is lost and  the adverse flexed position of the lumbar joints occurs which can be clearly seen.   Crossing of the legs accentuates this.   Note that none is using the backrest except for the doctor in the white shirt  who is in a semi-reclined slouched position.  In this mode the lower lumbar joints may be unsupported and flexed (but see below) and the posterior ligaments are stretched but the intradiscal pressure is reduced from 0.44 MPa to 0.27 MP as shown in a study in Ulm by Wilke (Wilke 2001).  If fully supported this is moving towards the 2T (3M) concept of  a reclined work position.  WWSN.4

 The physiotherapist in the check shirt is sitting forward on his seat in order to extend his hips slightly.    The table is too low for him and so he loses this advantage as he has to  bend down towards the table top.  In Wilke’s study bending forward about 20° with straight back and without arm support increased the pressure to 0.63 MPa up to 0.83 MPa, which was reduced  to 0.43 MPa WWSN.5when the elbows were supported.   The physiotherapist in the striped shirt has adopted  an extended position as he is able to brace himself with his arms.  This has the added advantage of forward rotation of the pelvis and so protection of the disc wedge angle. A work position, of this sort, was found to be the commonest (52%) in the quick study (below).   In the next picture I am seen using a stool shaped like a saddle.   My hips are extended but this advantage is lost as the table is too low.  A saddle seat becomes uncomfortable due to localised IT pressure. This happens less with the equestrian saddle due to movement.

http://sittingsafely.com/remediation-overview/Cambridge 2013, Practicality & ergonomics of sitting safely.

A pilot study, in 2013, of how we sit now by students, at Cambridge, working on a project for a 2Tilt chair in relation to desk interface  and office space indicates results, from a nearby office, that might surprise some people.   This was occasioned by the somewhat confused results of intradiscal pressure studies where there is a variation in sitting positions and units used and is also relevant to the single pMRI study (Smith 2006).  A more complete study is required.

Screen Shot 2013-09-24 at 19.25.36

 

 

 

 

 

Note that in the absence of reclined work chairs only15% + 3% were sitting upright.

The slouch.

Another reprehensible posture –  or is it?

Screen Shot 2013-10-23 at 14.22.53The popular slouched or slumped posture when sitting in an upright chair looks very wrong if  the misconceived ‘correct’ sitting posture, as excoriated by Mandal, and confirmed by the correct ‘preserve the lumbar lordosis’ dictum is accepted,   It is assumed that this posture will cause LBP if without support at the lumbo-sacral level. This may be true for Western societies where children have been universally accustomed to sit in ergonomically unsuitable upright chairs. This is an oversimplification when non-western sitting is taken into account.

slouchThe diagram shows that the flexion occurs at the upper lumbar joints with normal, or increased up to 40°, kyphosis of the thoracic spine. The pelvis lies fully on the surface of the seat and cannot tilt backwards.  The two lower lumbar joints, where IV Disc derangement typically occurs,  are safe if the wedge angles preserved.   The position is not very different from that in a semi-reclined chair.   In the 2Tilt (3M) version emphasis is placed on correct support from head to feet, with a slight degree of iliac support to prevent sagging at the lumbo sacral junction.  Wilke  found the L4/5 intradiscal pressure to be 0.27 MPa against  0.45 to 0.50 MPa when sitting upright (Wilke 2001).

The modern epidemic of backache is associated with lack of exercise and, In spite of uncertain epidemiological  evidence, prolonged upright sitting in chairs.    This is a relatively modern habit.    High backed chairs were an article of state and dignity.    Even monarchs used their thrones for limited and specific events.  Most people sat or squatted on the floor in various ways, which were culturally determined, and  benches and stools were the ordinary seats of everyday life.   It was in the 16th c. that the chair ceased to be a privilege, and became a standard item of furniture for anyone who could afford to buy one and the chair speedily came into general use and that is how we sit now.

Joint stoolJoint stool. These were made in large quantities in the 16th and 17th centuries. They were the most common form of seating before chairs became universal.  Users tend to perch with hips extended as recommended by Mandal.  People did not seem to be bothered much by backache. They were erroneously called ‘coffin stools’ in the 19th century.    Shown are two late 17th c. models.

Next see ☛ How other people sit

And   ☛ Various chairs.  How do they measure up? →  

See also a lighthearted account of the Victorian office. which also includes an account and treatment of RSI (WRULD).

Prevalence and economic cost of LBP.

 The increasing backache prevalence seems to be a genuine phenomenon of the 20th/21st centuries in Western societies at the same time as the increase in sedentary occupations and lack of exercise ..  The scale of mechanical  Low Back Pain (LBP) problems is confirmed by many studies from many countries.

Screen Shot 2018-06-11 at 21.35.22There has been a slight drop in prevalence in the last few years.  Perhaps it is presumptuous to suggest that this may be due to improved seating following my views put forward  in 1998 although a full 2T chair is not yet in the market.

LBP is the most common health problem for British workers. The Clinical Standards Advisory Group (Waddell), in 1994, in a study of the  backache prevalence and it’s cost  estimated that, since 1978 the  annual loss of working days due to low back pain had increased 200% to 150 million days.    A study in Manchester (Croft 1998) showed that 50% of women aged 45-50 claimed to have suffered from backache in the previous  month.  A prospective UK trial (Croft 1999) showed a 36% increase in prevalence of backache and incidence rate in 1 year.    Since then there has been a slight drop possibly due to better designed chairs, many of which are slowly approaching my views.

Back pain is also one of the most costly conditions for which an economic analysis has been carried out in the UK and this is in line with findings in other countries. It is estimated that the direct health care cost of back pain in 1998 to be £1632 million.  Approximately 35% of this cost is most likely paid for directly by patients. With respect to the distribution of cost across different providers, 37% relates to care provided by physiotherapists and allied specialists, 31% is incurred in the hospital sector, 14% relates to primary care, 7% to medication, 6% to community care and 5% to radiology and imaging used for investigation purposes. However, the direct cost of back pain is insignificant compared to the cost of informal care and the production losses related to it, which total £10668 million.  (Maniadakis N, Gray A. 2001)   (Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain. 2000 Jan;84(1):95-103.)

The Centre for Health Economics (CHE) showed a cost to the UK NHS of £265.3 billion – £382.7 billion in 1992-93.  https://www.york.ac.uk/che/pdf/DP129.pdf

The Work Foundation estimates that employees suffering from bone and joint pain cost the EU’s economies 240bn euros (£200bn) each year.  “Sitting is the new smoking,” explains Prof Steve Bevan, director of the Centre for Workforce Effectiveness at the Work Foundation.  “The more sedentary you are the worse it is for your health.”   The Lancet, published a study in 2012, which found that musculoskeletal conditions were the second greatest cause of disability in the world, affecting over 1.7 billion people worldwide.  “I describe suffering from musculoskeletal disorders as being like a Ferrari without wheels,” says Prof Woolf, who is also the chair of Bone and Joint Decade. “If you don’t have mobility and dexterity, it doesn’t matter how healthy the rest of your body is.”

In the United States About 100 million workdays are lost annually  (Johanning 2000).  Insurance figures show that 82% of US office workers complain of LBP (personal communication 2012 HAS),   Lower back pain’s economic impact is shown to be the number one reason for individuals under the age of 45 to limit their activity, second highest complaint seen in physician’s offices, fifth most common requirement for hospitalization, and the third leading cause for surgery.  (Health and Safety Executive‘s Better Backs campaign.https://en.wikipedia.org/wiki/Health_and_Safety_Executive).

The UK DoH (Dept. of Health, Dept of Children, Schools & Families.) issued an authorative report on ‘Sedentary Behaviour and Obesity: Review of the Current Scientific Evidence’. See  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/213745/dh_128225.pdf

“In conclusion, upper-extremity MSS (musculoskeletal symptoms) affected more than half of the study participants who used a computer for more than 15 hr/week (Gerr et al American Journal of Industrial Medicine 41:221-235,2002).

The actual increase of mechanical spinal pathology and backache prevalence seems to be a genuine phenomenon of the 20th century and is rising exponentially (Hemingway 1997) with the increase in sedentary occupations.”Mankind has progressed from Homo sapiens to ‘Homo sedans” (Mandal).

(Prevalence = the number of existing cases overall.   Incidence = the number of new cases in a given time.)

Next ☛BACKACHE? For users and patients (only)

Screen Shot 2013-10-13 at 14.47.34