B a c k / N e c k
Surgical and non-surgical interventions for spinal disorders
B a c k / N e c k
Orthopaedic and Spinal Surgeon
MBBS (Hons 1) MS (Ortho) Dip. Anat FRACS FAOrthA PFET (Spine) CIME
Adjunct Assistant Professor, Bond University, Queensland
P - 0499 NEC BAC
[0499 632 222]
F - (07) 3009 9992
P.O. Box 211 Isle of Capri QLD 4217
Spinal Health
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]
Negative
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Lowered mood and anxiety
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Fearful thinking and catastrophizing
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Feeling out of control or helpless, pessimism, defensiveness
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Obsessive, neurotic or hypochondriac tendency
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Being overly concerned about spinal damage or flareups when not justified
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Substance misuse
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Unresolved conflicts and dissatisfaction
ALIGNMENT
Protective
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Efficient centre of gravity (ie spine is well aligned, head over hips)
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Correction of generally poor posture via muscle retraining
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Well fitting supportive shoes that correct pronation / hindfoot overload
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Some patients find adjustable beds or certain mattresses better or worse for their symptoms
Negative
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Excess attention to mild posture issues
STRENGTH
Protective
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Good core strength including abdominal, pelvic floor and back muscles
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Good balance and 'proprioception'
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Good strength of compensation assisting muscles such as the glutes
Negative
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Converse of the above
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Carrying excess weight
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Attempting to lift heavy weights when not prepared or moving abnormally
FLEXIBILITY
Protective
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Maintenance of supple joints and flexibility, often with regular stretching or water therapy.
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Negative
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Overusing or reliance on bracing longterm
The effect of alignment impacting economical movements and increasing muscle work
ACTIVITY
Protective
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Regular aerobic exercise
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Regular resistance exercises (e.g. theraband)
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Appropriate activity graduation during rehabilitation phases
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Activity modification in the acute injury or postoperative phase
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Regular postural change (e.g. ergonomic sit/stand office setup)
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Correct lifting/bending technique
Negative
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Withdrawing from exercise
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Laying down excessively
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Excessive sitting (tight psoas, high lower back disc pressure)
NUTRITION AND MEDICATIONS
Protective
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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.
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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.
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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.
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Consideration for appropriate nerve modulating drugs for nerve pain, respecting the side effects and titrating up slowly
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Often a trial and error approach with different combinations of medications may be necessary to achieving the right balance.
Negative
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Excess use of alcohol, tobacco/illicit drugs and pro-inflammatory or gout producing diets
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Cannabinoid oils are have mixed evidence often with low success rates, common side effects (inc Driving) and high cost
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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).
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,
Level 3 exercises
