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Wrestling with the Spine Flexion Debate: Considerations and Nuances
- FITT Physio
- Feb 23
- 17 min read
Have you heard the advice “keeping your back straight/neutral when you lift”, or “lift with your legs?” The idea behind this is that we want to limit spine flexion, i.e., how much we bend or round our backs when we lift. The common belief is that spine flexion during lifting is not good for the spine. However, recent discussions and studies have offered counter-arguments against this belief (for example, see this Instagram post). There remain strong opinions on both sides, especially prominent in social media debates, where strong language and over-simplification of arguments are common unfortunately.
My interest in spine biomechanics and pain has been long-standing, so I have followed this debate for a few years. As a Certified Strength and Conditioning Specialist® practicing physiotherapy, I am especially invested in helping people get stronger, healthier and less pain. I have learned a lot about pain as the host of Paincast and being heavily involved in the Pain Science Division of the Canadian Physiotherapy Association. I have also learned a lot about biomechanics as an active clinician researcher at the Biomechanics Lab at the Faculty of Kinesiology and Physical Education of the University of Toronto. Uniquely positioned to understand arguments from both sides, I hope to provide a nuanced discussion of this debate to provide clarity and directions for both the public and practitioners (clinicians/fitness professionals). In this article, I first highlight the arguments for and against spine flexion and their counter-arguments, and then provide practical recommendations based on context.
Content
Rationale for Discouraging Spine Flexion
I have seen numerous social media influencers saying that deadlifting is bad for your back. Let's take a look at some scientific reasons why someone might think so:
Table 1. Arguments discouraging spine flexion and their counter-arguments.
Mechanism/Type of spinal injury | Arguments against spine flexion | Counter-arguments |
Disc herniation
| In cadaveric animal spine models, disc herniation occurred with a high number of bending cycles with modest loading, and the likelihood of herniation increased as compression load increased [1]. In another study, disc herniation occurred only in flexed segments under faster loading situations compared to no flexion or slower loading [2]. | Disc disruption can also occur in a neutral spine (no flexion). Veres et al. (2010) showed when subjected to a pressure impulse (a situation like falling on the buttocks), disc failures occurred more often in neutral spines compared to flexed spines, while vertebral failure occurred more frequently in flexed spines than neutral spines [3]. |
Vertebral damage/fracture:
| Vertebral failure occurred with smaller compressive loads when loaded in flexion compared to neutral [4].
| Gooyers et al. (2015) found no difference in neutral versus flexed spine injury rate in the highest loading condition, although there were differences in the types of injury sustained in flexed spines versus neutral spines [5]. |
Low back pain (LBP):
| The biomechanics of low back injury is well-studied. Injury occurs when the load exceeds the tissue failure tolerance. It can happen with a single exposure to a high load. It can also occur with repeated exposures to sub-failure loads or a sustained sub-failure load, leading to tissue fatigue and decreasing failure tolerance [45]. An analysis indicated the combination of five trunk motions and workplace factors associated with both medium-risk and high-risk occupational-related LBP: lifting frequency, load moment, trunk lateral velocity, trunk twisting velocity, and trunk sagittal angle [6]. In a 10-year cohort study, rowers and skiers, whose sport requires repetitive or sustained flexion, received more medical assistance for their LBP than orienteers (long-distance, off-track running) or non-athletic controls [7]. | There is a poor relationship between damage and pain. Not all disc herniations are symptomatic [8], and not all LBP is from disc herniations [9]. There is a poor relationship between imaging findings of the spine and LBP [10,11].
|
The table above presents the most prominent arguments discouraging spine flexion. Some other arguments are more technical and are beyond the scope of this article. Interested readers can listen to the Paincast episodes where I interviewed Dr. Tyson Beach (episodes 19-20). So, what can we make out of the above arguments and counter-arguments so far? I think we can conclude this:
Repeated flexion with loading is a known mechanism that can lead to disc or vertebral injuries according to cadaveric loading simulation studies.
To say neutral posture prevents back injury is an overstatement. Anything that exceeds the tissue tolerance of the spine can result in injury. However, injury to the spinal tissues is not always associated with pain. Pain is also not always associated with injury or damage.
Rational for Encouraging Spine Flexion
You may think: why would people argue for spine flexion? There are two types of arguments: those arguing against maintaining a neutral spine (Table 2), and those arguing for encouraging spine flexion (Table 3).
Table 2. Arguments against traditional lifting advice of maintaining spine-neutral.
Arguments against spine-neutral | Rationale for argument | Counter-arguments |
Flexion is unavoidable even if you try to maintain neutral
| Even though participants in biomechanical studies were asked to keep their spine as neutral as possible, there was still a considerable amount of spine flexion when they performed lifting tasks or kettlebell swings [12, 13]. Some, therefore, suggest that asking people to maintain a neutral spine during lifting is pointless because they will be flexing anyway. | Just because flexion is unavoidable doesn’t mean we should just freely bend under load. The same load is experienced differently in different postures, so not all flexion ranges are the same. Tissues experience an increased amount of stress as they near their end-range stretch, and are generally more prone to injury at end-range lengths [14]. This argument actually supports advising lifting with a neutral spine. If people are already flexed under the advice of keeping a neutral spine, more flexion will only occur without such advice. |
Manual handling training programs were ineffective
| It is well-documented that occupational training interventions of teaching proper lifting techniques have largely been unable to reduce LBP [15]. | It is inappropriate to conclude, therefore, that lifting techniques do not reduce LBP risks. For example, most “training” was didactic and did not measure whether workers changed their lifting behaviours. A more elaborate critique of this argument can be found here [16]. |
Appeal to personal observations
| Some argue, “I know lots of people who lift terribly but have no pain.” They argue, therefore, that lifting with spine flexion does not contribute to LBP. | Anecdotal evidence is a type of evidence, but it is very low quality. It is collected non-systematically, thus subjected to many types of bias. For example, those who don’t have LBP could continue to lift flexed, but those who developed LBP either stop lifting or change how they lift. This is survivorship bias. Having no LBP at a certain point in time also doesn’t prove that they won’t have it later. |
Most flexion activities are safe | Sitting involves a lot of flexion, but it is not injurious (it alone cannot injure you, but LBP with prolonged sitting is another topic). Activities like putting pants on, tying shoelaces, and picking up regular daily objects, involve spinal loading that is safely within the injury threshold [17,18]. Flexion in most activities should not be feared. People shouldn’t feel as if they should keep a straight spine in absolutely everything. | This argument is sensible to me. In fact, negative beliefs about movement can be associated with pain development [19]. That being said, clinically, I have also had patients report “their backs gave out” while picking up things as little as a piece of paper. Even though the load would have been sub-injurious, it doesn’t mean that it can’t be the straw that breaks the camel’s back. The process of injury could have already happened with previous loading exposures such that a seemingly safe flexion was the inciting event. However, to fear and avoid bending is unproductive. Consult a physical therapist if you find that you are struggling between pain and movement fear-avoidance. |
Lack of epidemiological evidence | A systematic review and meta-analysis concluded that greater lumbar spine flexion during lifting was not 1) a risk factor for LBP onset/persistence or, 2) a differentiator between people with and without LBP [20]. The same author group later did a cross-sectional study and found that manual handling workers with a history of LBP lifted with less flexion than their counterparts without a history of LBP. The authors stated in their conclusion that their study “provided the best quality in-vivo laboratory evidence to date that greater intra-lumbar flexion is not associated with LBP in manual workers.” The authors thus questioned the basis of traditional lifting advice, implying that this advice might be perceived as creating a need to protect the back, which may be detrimental [21]. | These papers become popular citations when arguing against lifting with a neutral spine. However, they need to be examined further to evaluate their power in supporting this argument. The authors of the systematic review and meta-analysis rated the overall quality of the studies as “low” due to the high risk of bias [20]. Further, risk factor implies something that increases the chance of developing LBP. This means that there should be a temporal relationship between lumbar flexion during lifting and the development of LBP. While 12 of the 13 studies included in the meta-analysis were cross-sectional rather than longitudinal studies, no temporal relationship between lumbar flexion during lifting and LBP onset could be established. Similarly, the study on manual handling workers was cross-sectional, which is an inappropriate study design for their conclusion and recommendation [22]. |
Table 3. Arguments encouraging spine flexion.
Arguments for spine flexion | Rationale for argument | Counter-arguments |
Lifting with flexion is more efficient
| A study suggested that a flexed-back posture during lifting is associated with increased strength and efficiency of the back muscles [23]. | This is not surprising: squatting down to pick up something is more metabolically demanding than if you keep your legs straight and bend over. However, simply because flexed-back lifting is easier doesn’t mean it is better. It depends on the context and purpose. A more elaborate discussion of this argument can be found in Paincast episode 20. Emerging evidence also suggests that posture alone cannot infer overall lifting strength because the effect of posture on strength varies across individuals [24]. |
Being prepared for potentially demanding flexion activities in life
| Some argue that since avoiding spine flexion under load in life is impractical, deliberately exposing the spine to flexion under load in training is the only way to prepare for these movements in life and reduce injury rates from awkward lifting [25]. They, therefore, advocate for dedicating some training to lift with spine flexion. | This may be true, but I have yet to see any evidence supporting this claim. Besides, although we can’t control what is to come in work, life, or play, movement patterns emphasized in training are carried over to novel tasks [26]. There are probably a few scenarios in life where adjusting your lifting posture is not feasible. Whether deliberate training loaded flexion is worthwhile may depend on individual preferences and circumstances. |
Tissues in the spine can adapt | There is some recent evidence suggesting that discs can positively adapt to loading with running [27] and cycling [28], having increased hydration and proteoglycan content. Another study found that basketball and soccer were beneficial for disc health in younger athletes, though longer training careers and volumes had a weak association with worse disc hydration [29]. A well-hydrated disc is important for its ability to withstand compressive loads and maintain disc height. Evidence also suggests that vertebral bone mineral density increases with loading [30]. | This line of evidence does not specifically encourage lifting with a flexed posture, because you can still derive these adaptations by loading the spine in neutral. However, it may suggest that loading in flexion is not as injurious as it sounds when progressed appropriately. That being said, we don’t know the proper amount of loading in flexion which is productive versus counter-productive for tissue adaptations. |
Contextual Factors to Consider
The above provided a concise summary of the arguments on both sides of the spinal flexion debate. Readers interested in a more in-depth discussion can read Howe & Lehman [31]. As we move on to understand how these all apply practically, as a rehab and fitness professional, I would be remiss if I didn’t mention important considerations beyond biomechanics, as biomechanics is only ONE of the many factors at play in LBP. Here are a few examples:
A Biopsychosocial lens
Lifting technique may or may not be relevant to someone’s LBP. Apart from biomedical/biomechanical considerations, psychological and social factors can contribute to pain. Dave Walton’s pain assessment radar plot recognizes 7 domains of pain, including areas like emotional, cognitive, and socioenvironmental contexts [32]. Cognitive Functional Therapy for LBP recognizes 8 domains, including patho-anatomy, physical, emotional, cognitive, health, sensory, social, and lifestyle [33]. Understanding the interaction of various pain drivers can help with contextualizing the flexion debate. For practitioners, this means considering the whole person and not only the pathoanatomical. For non-practitioners, this means understanding that many factors contribute to the pain experience, and that pain is not always related to posture.
The power of communication
The power of language to provide a nocebo or placebo effect is well-documented [34]. There is a strong positive relationship between beliefs and outcomes [34]. Being overly anxious about bending over to the point of fear avoidance is unproductive and could potentially provoke pain mechanisms [35]. Therefore, for practitioners, depending on the person you are working with, you may or may not want to stress your beliefs about lifting with a neutral spine. For non-practitioners, as the saying goes, “motion is lotion”, I recommend having a general movement optimism, seeing most movement as good rather than harmful.
Individual variability
There is no universal way to lift. Variability in people’s anatomy drives different lifting preferences. A nice discussion on this point can be found here [36]. This is where, as a rehab or fitness professional, you can problem-solve with your clients and explore patterns that enable them to lift most comfortably and safely. Genetics is another major factor determining one’s predisposition to spine pathologies [37-39]. While genetics is unmodifiable and lifting technique is modifiable, understanding this strong factor influences the risk of someone developing LBP is helpful to get a bigger picture regarding lifting and training in general, and not get caught up with the details.
All of the above factors point to a person-centred approach, which includes adapting your approach and language as you work with different clients given what you understand from the arguments and counter-arguments.
Context Matters: A High-level Practical Guide
Note that the following guide is only a starting point and does not constitute medical advice. A detailed assessment by a qualified professional is important to determine the appropriate steps to take.
If someone already has LBP
Acute LBP: With any acute (new) injury, follow the PEACE+LOVE principle [40] and “calm things down, build things up.” [41]
Mechanical LBP: In a thorough assessment of someone presenting with LBP, factors contributing to LBP will be identified. Once they are addressed, in most cases, LBP can be improved. If you have determined that lifting technique is relevant to someone's pain, consider using a gentle correction approach while prioritizing movement and exercising, which has much greater effectiveness for persistent pain management than other modalities (see the Clinical Practice Guideline for LBP [42]). Both the McGill and McKenzie methods offer an evidence-based and structured assessment and treatment approach to LBP and have patient self-help books. Lastly, offering patients different lifting options can “unlock” their movement variability and start to get creative about how they perform a lifting task. As LBP improves, gradual reintroduction to lifting heavy and even awkward lifting can be a part of the rehab depending on the goal of the patient.
Nociplastic LBP: Nociplastic pain refers to pain disproportion to actual tissue damage due to altered pain perception [43]. Patients may develop persistent LBP with high levels of pain with or without movement. Because the major cause of pain is altered pain perception and modulation and not tissue damage, it is counterproductive to reinforce the danger of flexion [19]. Patients should be encouraged that their spine is strong and that all movements are beneficial. To address fear avoidance of flexion, use graded and guided exposure to flexion activities. You can reference the Cognitive Functional Therapy approach [33]. Pain-informed Movement [44] is another great approach.
If there is no LBP
Strength training: I personally still coach lifting with a neutral spine, but stressing that they don’t need to overthink this in everyday life. For the general population, I prefer to develop their physical literacy, strength, and ability to control their bodies with different external loads. People can benefit from know how to do a good hip hinge. People should be able resist to not let the weight “pull” them into flexion. As we get into heavy lifting endeavours, I think evidence still favours neutral while lifting; we do not have any favouring flexion. What is encouraging is that movement patterns can be carried over from a movement-aware style of coaching and training to functional tasks outside the gym [26]. However, as discussed above, tissues can still be injured even in neutral if the loading exceeds their tolerance. Therefore, following a progressive overloading approach and providing sufficient time for adaptations to occur is important. On the flip side, if someone wants to develop resiliency of the back, I don't necessarily see the danger in adding some deliberate awkward lifting during training, for those who already have a good foundation of basic lifting and a good movement literacy/awareness. After all, not all of life looks like a deadlift at the gym.
Athletes: This depends on the sport and whether the athlete is struggling with LBP. Generally, being able to stiffen the core (i.e., stabilize the spine) is beneficial for effective power transfer between the lower body and the upper body, which is important for performance in many sports.
Elite powerlifters: In maximal lifts where performance is crucial, controlled flexion in deadlifts provides many advantages. However, the risks and benefits must be weighed, and there must be sufficient time for recovery between maximal lifts. In squats, however, a sloppy back would be detrimental to performance.
For yourself: With a topic like this, there is no black or white. Everything is context-dependent. I have done my due diligence to read and distill the literature, but I am not immune to getting something wrong. I hope everyone can have an inquisitive attitude in discussions, be charitable with arguments, and have a healthy dose of skepticism. Be an open-minded critical thinker, and be willing to update/nuance your view with new evidence from rigorous research.
Conclusion
This article provided a comprehensive summary of the arguments for and against spine flexion, each accompanied by a counter-argument to help readers gain a fuller picture of the spine flexion debate from both sides. A few contextual factors have been explained to help readers understand nuances in practical considerations, advocating for a person-centred approach. The final section is a starting point for the readers to understand how these nuances in practical settings are applied. It exemplifies how the application of the spine flexion debate arguments differs between populations.
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