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The Neutral Spine Position
The first thing to do is to identify the neutral spine position. This is a position where the spine is pain free and not under any strain. All the exercises you do should be done while keeping the spine in this neutral position.
This position may vary for each individual, depending on the pathology. Lie on your back, with your knees bent. Get a friend to put their hand under your back. Gently press this hand against the couch.
Now, while maintaining this gentle push against the couch, lift one leg up. You will find your back arches away from the hand. You have moved away from the neutral spine position. Try again. Once you have mastered this go through the following steps:
- 1. Raise one foot
- 2. Raise the other foot.
- 3. Raise one arm.
- 4. Raise the other arm.
- 5. Raise one leg.
- 6. Raise the other leg
- 7. These can also be performed using weights
Another way of achieving the “neutral” spine position is to tighten the muscle between your tummy button & the top of your pubic bone. You will probably find that you held your breath whilst performing this! Practice tightening & breathing normally, it may help to recite a nursery rhyme or count as then you have to breathe normally. Once you are able to do this you may start the spinal fitness programme.
Key points in the lumbar stabilisation program
1. The spinal muscles help to support the spine. A strong muscle helps to protect the joints underneath it ~ as athletes know only too well. Strong and flexible spinal muscles help to reduce the load going through the spine itself. People with weak spinal muscles, are more prone to injury. People with back pain have reflex wasting of the spinal muscles and this makes them more prone to injury, setting up a vicious cycle.
2. The only way of breaking this cycle is to strengthen the muscles, stabilising the spine. We also know from athletes that the best way to treat soft tissue injuries is by early rehabilitation. This improves circulation and tissue remodeling – helping tissues to heal faster. The old concept of long periods of bed rest has been shown to actually make people worse.
3. The key muscles for spine control are the abdominal muscles, the spinal extensor muscles (on the back) and the oblique rotator muscles on the side. A YMCA study reported greater pain reduction with improvement of trunk muscle strength.
4. It is important to begin the exercises well within your capacity, to avoid any injury. Gradually increase the duration and the load of the exercises every week. It will take 3 months before you begin to notice the difference in your back. Trying to strengthen your muscles requires them to be gradually loaded over a long period. Finding the determination and the motivation to persevere is vital. You have to take responsibility for getting your own back better. Having a positive attitude is a key ingredient of success. Develop a routine for exercise, just like you brush your teeth every morning.
5. When you first start you may notice an increase in your pain. This is okay, and represents an ache from stiff muscles and joints. This pain does not mean that you are damaging your spine further. If for example, your knee had been in plaster for 3 months, it would hurt when you started to move it, because of the stiff muscles and joints. The key of course would be to keep the exercises going, working through the initial pain. Similarly in the spine.
6. Begin doing these exercises once your acute pain episode has settled. You can also begin if you have chronic back pain, which is as good as it usually gets.
Key components of the programme
FLEXIBILITY: Begin with a gentle whole body, stretching program. Include the shoulders, the neck, the hamstring muscles, the quadriceps and of course the spine. Stiffness in one area can increase the stress transmitted to an adjacent area.
FLOOR BASED STABILISATION PROGRAMME: This is described in detail later on in this document.
AEROBIC FITNESS PROGRAMME: Improving your overall aerobic fitness will help reduce your back pain and also strengthen your spine. Cycling on an exercise bike, swimming or jogging in the water and fast walking on a treadmill are all exercises that do not usually strain the back.
Skipping is also very good if your back will tolerate it. Aerobic exercise also results in the secretion of endorphins, which are the body’s own natural painkillers. Try and gradually increase the amount of exercise you do ~ and vary the exercises to stop boredom.
BACK MUSCLE STRENGTHENING: Strengthening your back extensor muscles, is a key component of spinal stabilisation. Some Gyms have Spinal Extensor Strengthening Machines. One sits down with a bar across the back, which one can push against. This machine allows the load to be gradually increased and improvement can be measured. An alternative is to hang face down over the edge of a flat surface, let the trunk hang down and pull it up again. This does require a certain an amount of fitness beforehand however.
Research has shown that up to 85% of patients can return to work after completion of this program. You need to set yourself clear goals for recovery, understanding any factors, which may interfere with your motivation to get better.
Using this exercise program
- 1. First work at identifying your neutral pain free spine position. If you have difficulty with this you could get help from a physiotherapist.
- 2. Then use the exercise sheets to do the different exercises. Start at the beginning of each section. You may find some more difficult than others may. Do not progress until you are comfortable with the earlier level. You may find yourself at ‘level 1’ of one exercise and at ‘level 3’ of another.
- 3. All the different exercises complement each other. The sequence does not matter.
- 4. Begin each session with some stretching. Combine the stabilisation exercises with aerobic fitness exercises. Be patient. Be regular. Remember! It takes 3 months to notice the difference.
Hold the spine in the pain free neutral position.Count to 10 and relax. Abduct the hands to under the head. Brace the abdominal muscles to a count of 10 and relax. Repeat x 3.
Alternatively flex and extend the fully straight arms, maintaining the neutral position.Count to 10. Relax. Repeat x 3.
Tighten trunk muscles in neutral position.Bend one hip and knee to 90 degrees. Hold to 10. Repeat with other leg x 10. Repeat x 3.
Combine above 2 maneuvers with alternate arm extensions and hip flexion. Left arm – right leg, then right arm – left leg. Maintain tight neutral position. Repeat x 3.
Shoulder flexion with alternate lower extremity extension. Count to 10. Repeat x 3.
Repeat with alternate leg extension without putting a leg onto the ground. Repeat x 3. Maintain neutral position
Place the feet firmly on the floor. Brace the abdomen. Place the arms across the chest and raise the shoulders and back off the floor.
Keep the neutral pain free spine position. Do the exercise slowly. Count to 5 before lowering yourself to the ground. Vary the manoevre by bringing the head up towards the left knee and then the right. This will exercise the oblique abdominal muscles. Gradually increase the severity of the exercises you do according to the chart below.
Level 1: Forward, Hands on Chest 1 x 10
Level 2: Forward, hands on Chest. 3 x 10
Level 3: 3 x 10 Forward, 3 x 10 Right, 3 x 10 Left
Level 4: 3 x 20 Forward, 3 x 20 Right, 3 x 20 Left
Level 5: 3 x 30 Forward, 3 x 30 Right, 3 x 30 Left
Add weights to chest as an option.
The bridging exercises strengthen primarily the gluteal, quadriceps and hamstring muscles. You must attempt to lift the buttocks off the floor, hinging at the hip joint, whilst trying to make a straight line from the shoulders to the knees.
Level 1: Raise the hips one-inch off the floor and maintain the neutral pain free position for a count of 10. Then raise the hips further off the floor to the maximum height comfortably possible, whilst maintaining the neutral position. Hold to a count of 10 and then return. This is not a back arching exercise. Repeat 2 x 10.
Level 2: Repeat the above. 2 x 20
Level 3: Raise the hips 3 inches off the floor and hold. Extend one leg while maintaining the back in the neutral position. Hold for a count of 10. Place the foot on the floor and rilax. Repeat with the other leg 1 x 20.
Level 4: Repeat above 2 x 20
Level 5: Repeat above 3 x 20
These exercises help in trunk control. You need to learn to hold the back in this position with the trunk muscles tight.
Level 1: In the all fours position with the knees and hands on the floor, tighten the trunk musculature and hold the spine in the neutral, pain free position and relax.
Level 2: In the all fours position, with the knees and hands on the floor tighten the trunk muscles and hold the spine in the neutral pain free position. Extend one arm, hold for a count of 10 and relax. Repeat with the other arm. Repeat 2 x 10.
Level 3: Get into the position described above, but this time extend one leg, hold for a count of 10 and relax. Repeat with the other leg. Repeat 2 x 10.
Level 4: Get into the position as above. Alternately lift one arm and the opposite leg, at the same time, maintaining the neutral position at all times. Repeat 2 x 10.
Level 5: Repeat level 4 with weights strapped to the arms and legs. Repeat 2 x 20.
These exercises are good for strengthening the quadriceps. Beginning with gentle knee flexion and no rial lower extremity or back strain.
You can do this with an exercise ball behind the back. As shown in this picture, but this exercise can also be done with the back directly against the wall. Position the back against the wall. Keep the arms by the side. Tighten the trunk muscles and get the spine into the Neutral pain free position. Gently slide the back down the wall, bending the hip and the knee. As your capacity to do this exercise improves go down some more until the hips and knees are bent to 90 degrees.
Keep the spine in the neutral position.
Level 1: Less than 90 degrees. Repeat 1 x 10
Level 2: 90 degrees. Maintain for 20 seconds. Repeat x 10
Level 3: 90 degrees. Hold 30 seconds. Repeat x 10
Level 4: 90 degrees. Hold arms extended with weights. Hold 30 seconds. Repeat x 10
These exercises are meant to strengthen your back extensor muscles. Some back conditions are painful so do these exercise with 2 pillows under your pelvis.
Level 1: Tighten the gluteal and abdominal muscles whilst lying face down over 1 or 2 pillows under your pelvis. Count to 10 and rilax. Repeat 1 x 10. Keep trunk in neutral pain free position.
Level 2: Prone with alternating arm and leg lift, whilst maintaining the neutral pain free position. Alternately do one arm, then the other arm, one leg and then the other leg. Hold to a count of 5. Repeat 2 x 10.
Level 3: Prone alternate arm and leg lifts. Maintain the neutral position while lifting the opposite arm and leg simultaneously off the ground. Hold for a count of 10 and rilax. Repeat x 20.
Level 4: Prone with double arm lifts alternating with double leg lifts. In the neutral position and lift both arms off the ground. Count to 10 and rilax. Then in the neutral position lift both legs into the air. Count to 10 and rilax. Repeat x 20.
Level 5: Prone double arm and leg lifts. Maintain the neutral position while lifting both arms and legs off the ground.
AEROBIC CONDITIONING: The key is to vary the type of exercises you do, so that you do not get bored. Try and gradually increase the volume of exercises you do. You need to get your heart rate up.
Check with your GP if you have any heart condition, which may interfere with your training program.
WATER JOGGING: Running in the water is an excellent way of improving your conditioning. Do it in shallow water in the swimming pool. Keeping the back straight. Begin gently by just walking fast in the water.
Move on to jogging in the water. If you have a buoyancy vest you can do it in 8 feet of water and run on the spot. You could also join a water aerobics class. Gradually improve your speed and duration of jogging.
SWIMMING: You need to be a good swimmer to swim without straining your back. Avoid the breaststroke, because it arches your back. The crawl or the backstroke is quite good. Again begin slowly, and increase the duration you swim.
CYCLING: An exercise bike is an excellent all weather way of keeping aerobically fit. The semi-reclining bike supports your back, which is better for your back.
WALKING: While walking is good for you, you do need to walk fast to get a sweat up and get aerobically fit.
SKIPPING ROPE: Use a short rope and do a 2 step jump. Count the number of jumps. Progress to an alternate step jump and eventually to a shorter rope. Begin with 15-second intervals. Gradually increase the number of jumps. This may not suit all patients. Try it and see.
With all the above activities keep a chart and try and improve your fitness on a weekly basis. Begin gently and slowly. Keep within your pain tolerance. Increase the volume of exercises gradually.