Spinal Health

Caption: Asst/Prof Zotti playing for Australia at the World Medical Football Championship 2024

The preconditions to good spinal health and function are both obvious and subtle - the importance of harmony of these different factors for good spinal health is especially apparent when one or more of these factors is absent or dysfunction and pain and disease occur. Much of the following philosophy is evidence based and paralleled to advice from spinal organisations organisations such as the North American Spine Society (9 for Spine - www.spine.org) and American Academy of Orthopaedic Surgeon (Spine Conditioning program - AAOS.org). This advice is for general understanding and principles is not intended as a substitute for medical advice; exercises are suggestive based on core stabilisation principles with a prescription and ongoing assessment by a qualified exercise physiologist, physiotherapist or personal trainer advised.

The biopsychosocial model of chronic pain and 'vicious cycle' [above]; The many benefits, including to the spinal and musculoskeletal system, of regular exercise [Right]

MIND

Protective

Social support
Mentality of being in control and putting things in perspective
Positive mindset
Positive messages about movement
Pacing and sleep hygiene
Calm, peaceful, thoughtful and reliable personality

The role of the mind in pain - Dr Hanscom, Spinal Surgeon

Negative

Lowered mood and anxiety
Fearful thinking and catastrophizing
Feeling out of control or helpless, pessimism, defensiveness
Obsessive, neurotic or hypochondriac tendency
Being overly concerned about spinal damage or flareups when not justified
Substance misuse
Unresolved conflicts and dissatisfaction

ALIGNMENT

Protective

Efficient centre of gravity (ie spine is well aligned, head over hips)
Correction of generally poor posture via muscle retraining
Well fitting supportive shoes that correct pronation / hindfoot overload
Some patients find adjustable beds or certain mattresses better or worse for their symptoms

Negative

Excess attention to mild posture issues

STRENGTH

Protective

Good core strength including abdominal, pelvic floor and back muscles
Good balance and 'proprioception'
Good strength of compensation assisting muscles such as the glutes

Negative

Converse of the above
Carrying excess weight
Attempting to lift heavy weights when not prepared or moving abnormally

FLEXIBILITY

Protective

Maintenance of supple joints and flexibility, often with regular stretching or water therapy.
Negative
Overusing or reliance on bracing longterm

The effect of alignment impacting economical movements and increasing muscle work

ACTIVITY

Protective

Regular aerobic exercise
Regular resistance exercises (e.g. theraband)
Appropriate activity graduation during rehabilitation phases
Activity modification in the acute injury or postoperative phase
Regular postural change (e.g. ergonomic sit/stand office setup)
Correct lifting/bending technique

Negative

Withdrawing from exercise
Laying down excessively
Excessive sitting (tight psoas, high lower back disc pressure)

NUTRITION AND MEDICATIONS

Protective

Balanced diet that promotes stable weight, good muscle strength and healthy immune and nerve function; bone, joint and muscle health. Anti-inflammatory, high value protein and ferritin boosting diets have shown evidence.
Some nutraceuticals and complimentary medicines have shown promise here or are being researched regarding their evidence include palmitoylethanolamide (PEA), magnesium, Devil's claw (Harpagophytum), tumeric, myrrh, Rosemary, rosehip oil, caryophyllene, B6, alpha-lipoid acid, acetyl-L-carnitine, Ginger, Boswellia Serrata, unsaponifiable avocado-soybean fractions, Lion's mane mushroom, Tongkat Ali and Fish oil. Consult your general practitioner before any wholesale changes to supplements.
Usage of simple, non-opioid medications to manage chronic pain. Long acting paracetamol and selective non-steroidal are examples of appropriate first line agents for musculoskeletal pain.
Consideration for appropriate nerve modulating drugs for nerve pain, respecting the side effects and titrating up slowly
Often a trial and error approach with different combinations of medications may be necessary to achieving the right balance.

Negative

Excess use of alcohol, tobacco/illicit drugs and pro-inflammatory or gout producing diets
Cannabinoid oils are have mixed evidence often with low success rates, common side effects (inc Driving) and high cost
Excessive reliance on opioids medications and poly pharmacy (mixing too may different types of pain relieving agents)

The four walls (left) that support the lumbar spine - the multifidus muscle (right) is almost always involved (see varied degrees of severity of fatty atrophy- right image) in people suffering low back pain
There is now a large body of scientific research in the last 10 years focussing on the role of multifidus and its prominent role in spinal health and dysfunction - it is an acknowledged target, along with other local muscles such as the gluteal muscles and transversus abdominus, for rehabilitative strengthening. Below are two examples of multifidus strengthening techniques (Lumbar extension machine and Roman Chair).

kettler-roman-chair-low-extension_1_99d2fb149b583558918d1a6649fd5a7e.jpeg

Evidence supports resistance extension training in preventing need for-, prehab for- and rehab from surgery

Managing new (acute) low back pain episodes or 'flare ups'

- Spine Conditioning Program (American Academy of Orthopaedic Surgeons)

- Can be trial and error and involve combination of below.

- Emphasis should be on ACTIVE therapies (Gentle exercise e.g. Walking, physiotherapy, hydrotherapy, pilates, Yoga, Tai Qi, Stretching, Swimming, backwards walking, light resistance activity e.g. Theraband)

- Use of home based stretches and exercises e.g. Exercise section on www.spine-health.com or healthline.com/health/lower-back-stretches (if symptoms ongoing for more than a few weeks it is recommended to visit a healthcare professional for assessment and supervision)

- Relative rest from temporary activity avoidance of aggravating activities

- Use of heat and paracetamol with judicious use of muscle relaxants and anti-inflammatories has supportive evidence. Ice is generally only advised the first 48 hours.

- Use nerve glides (pictured) for nerve pain down the legs

- For flare-ups lasting more than 4-6 weeks then adding in biofeedback, psycho-neuroeducation and pain education strategies are shown to be helpful

- PASSIVE therapies can be added in & can improve feelings of wellbeing but have generally short term effect & mixed evidence regarding their efficacy (acupuncture, chiropractic/spinal manipulation, mobilisation, needling, massage, traction, laser, ultrasound etc.)

Acute neck pain/arm pain referred neck episodes

- As above

- Temporarily limit overhead reaching and repetitive above shoulder activity

- Utilise nerve 'flossing' and nerve 'glides'

- Thoracic mobilisation (interscapular supine strech / 'bow and arrow') and shoulder rolls in the case of round shouldered postures. Protraction/retraction using towel behind head.

- Massage of Sternocleidomastoid including into its attachment 'K Point'

Prevention and maintenance

- Prevention - keep moving & incorporate some level of resistance whether it be controlled weights,stretch bands or against water (hydrotherapy/swimming). Core strengthening and trunk proprioception can be facilitated by performing daily exercises at home using aids such as exercise balls, weights & mats with progression supervised/prescribed by a health professional (e.g. physiotherapist, exercise physiologist) if you have been injured recently.

An example of progression through one of the common but many core directed exercises often prescribed is shown above with 'planks' and prone exercises on a Swiss inflatable ball, bridges, bent over rows, single leg extensions, upside down kettle bell and 'Dog-bird' cross arm activation, dead bugs, kettle bell pulls, hollow/banana, pelvic tilt, air bicycle and bear walks, Pallof press are other commonly used prescriptions. The McGill 'big three' are also evidence based and commonly used. Suspension (e.g TRX) system is another therapy that can be done at home with scientific evidence. Other evidence based exercises that strengthen core and back muscles are described (and backed by science) in the links directly below for interest:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3806175/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7345922/

Useful stretches - Psoas, McKenzie/Cobra, Bow and Arrow, Knee to chest

Examples [Only attempt after level 1+2 mastery] -

Crane, Deep squat, Iceskater, Ball assisted situp,

Leg curl, Supported T Fly, Supported reverse extension

Weighted iceskater, Resisted neck rotation/proprioception

RESOURCES / USEFUL LINKS / APPS:

Cervical exercise: The backbone of Spine Treatment - www.spine.org

Spine Conditioning Program (American Academy of Orthopaedic Surgeons)

Pain education : Lorimer Moseley - Explain pain book and tamethebeast.org ; painrevolution.org;

painmanagement.org.au Mindfulness: Curable app ; noigroup.com; Back in Control - David Hanscom MD

9 for Spine - 9 Back-to-Basics tips www.spine.org

Back strength principles: Back Mechanic by Stuart McGill ; rehabhero.ca ; theprehabguys.com

Youtube - James Dunne - Pallof Press

Choi, G., Raiturker, P. P., Kim, M. J., Chung, D. J., Chae, Y. S., & Lee, S. H. (2005). The effect of early isolated lumbar extension exercise program for patients with herniated disc undergoing lumbar discectomy. Neurosurgery, 57(4), 764-772.

Steele, J., Bruce-Low, S., & Smith, D. (2015). A review of the clinical value of isolated lumbar extension resistance training for chronic low back pain. PM&R, 7(2), 169-187.

Level 1 Stretches and Exercises

Level 2 Stretches and exercises

Selected examples [See above resources for other stretches] - Seated multifidus, Hydrotherapy, Bridges, Dog-bird, Cat-Camel, Cobra/Hip, Plank, Assisted knee-chest, Gluteal stretch, Seated flexion and trunk rotation, Side plank, Thoracic/Chest opening, Upper cervical flexion, Psoas, Thoracic bow and arrow, Lumbar/Sciatic nerve floss/glide, Cervical nerve glide/floss, Woodchopper resisted, Oblique resisted, Inverted farmer's walk,

Examples [Note level 1 exercises can become level 2 with modification] - pictures above - air bicycle, dead bugs, hollows, deep glute stretch, lying cat-dog, bear crawl, wobble board, prone multifidus (superman), Alter-G reduced gravity treadmill, one arm row, supported wall squat, resisted retraction-protraction, crab walks,