In Part 2 of this 3-part series we’ll explain the importance of how to improve your “core” strength and strength and flexibility of your hips. I would like to recognize the work of Dr. Stuart McGill of the University of Waterloo, Canada, who has been studying the spine as it relates to injury mechanisms, prevention and rehabilitation for 30+ years. The recommendations that follow assume that the patient has completed an assessment of his/her body alignment and received any required treatment to correct it.
First, what is the “core” and what role does it play in spinal health? For those without any previous anatomy training, the core includes muscles that are located in the trunk of the body, front and back, attaching to the spine with some attachments to the pelvis, that work together to balance forces on the spine created by movements, sustained postures, bracing against unexpected forces and forceful breathing.
Some are responsible mainly for movement (bending, extending, side bending, twisting), others create stiffness, and still others act as position sensors, tracking the position of each vertebra. No one muscle is more important than another. The core muscles must maintain low but continuous muscle contraction to provide the necessary stability of the lumbar spine. The other tissues, ligaments and fascia, also play an important role in spinal stability.
The amount of loading on the spine varies from movement to movement, and, as was stated in Part 1, individual tolerance to loading varies a lot. In order to strengthen the core safely, we must select stabilization exercises that place the lowest load on the spine.
Before discussing specific stabilization exercises there are 2 important things you must be able to do. The first is brace with the abdominals; the second is to learn how to maintain a neutral spine. Their importance will be mentioned again in Part 3 of this series as it pertains to performing activities of daily living (ADLs) and work tasks.
Abdominal bracing means stiffening the muscles of the torso to create a girdle around the spine without moving the pelvis. To understand this, imagine someone is about to punch you in the abdomen and you brace for the blow. The contraction is light for most activities and you should be able to breathe normally.
What about the neutral spine. Imagine your pelvis is a bucket filled with water. If you keep the bucket level you don’t spill water. If you tip your pelvis forward (by exaggerating the lumbar curve) you spill water in front, and the opposite is true if you allow the pelvis to tip back (by slouching). Stand and tip your “bucket” forward and then back, then find the position where you are not “spilling” any water. This is the neutral position and puts the least amount of strain on the lumbar spine. You should also notice that the head and torso correct their position over the pelvis when you do this.
The lumbar curve should be maintained when doing the stabilization exercises (and during ADLs as we’ll read in Part 3). When the lumbar curve is maintained there is lower load on the spine.
- Before starting any of the following exercises, check with your doctor first to discuss your readiness for exercise. When performing the exercises you should feel NO PAIN. Try to perform the sequence daily. Aim for twice a day when you have greater tolerance to exercise. A typical daily plan would look like this: Start with the cat-camel exercise first thing in the morning. This exercise introduces gentle motion in your spine but not designed to be a stretching exercise. Get on hands and knees so knees are directly under the hips and hands directly under shoulders, smoothly flex and extend the spine from the low back to neck 6-8 times with continuous slow movements avoiding extreme ranges of motion. Rest 30 seconds and repeat. The goal is to flex and extend the spine to decrease inherent spinal friction or resistance to motion. http://www.besthealthmag.ca/best-you/stretching/cat-camel-back-stretch/
- Go for a walk as briskly as is possible for 15 minutes at first. You may have to begin with walking in place with good posture and gentle abdominal bracing. Increase distance as tolerance increases. If tolerance is low, increase frequency so you are doing multiple short walks throughout the day. Your eventual goal is to walk 3 times per day up to 30 minutes. Speed is an important factor in spinal loading. Strolling at slow speeds increases load because loads are almost static. Faster walking with an arm swing (moving from the shoulder) reduces load because the spine is cyclically loaded with the arm swing, providing some momentum to move the upper body. Walking faster doesn’t mean taking long strides though as this can result in over striding, putting more stress on the feet as they hit the ground and more force moving all the way up the chain into the hips and pelvis. Keep your feet under you!
- Later in the day (mid-morning to early evening) you can perform spinal stabilization (core) exercises including side bridges, the curl up, and the bird dog. These exercises are described in greater detail below using a video you can access with the link provided. Every day, do 6 reps with 10 sec hold, rest for 20 sec. Do 4 reps with 10 sec hold, rest for 20 sec. Do 2 reps with 10 sec hold. With this formula it will take approximately 10 min to complete the 3 exercises. If you find you can’t tolerate this much, you can try 5, 3 and 1 respectively of each exercise with the same rest periods or you can break up the whole sequence over 3 shorter exercise sessions over the course of a day. The idea is not to overdo it which means PAIN-FREE. Listen to your body and only increase reps if you are pain-free.
- You can introduce exercises to increase flexibility in your hips as tolerated. Include the hip flexor stretch, hamstring stretch with a neutral spine, the figure 4 buttock stretch and hip strengthening exercises starting with the clam shell, progressing to the side leg lift, then glute bridging, squats with a neutral spine and abdominal bracing (imagine you are about to sit on a stool), and lunge walking. See below for links to videos/instructions that explain each exercise. The number of reps and sets you do depends on how you feel. Start small and see how you feel the next day. Once you can do a full set of 12 reps pain-free, rest and add a few more in the second set until you reach 12 reps. You may or may not get beyond 1 set. Know your limits and honor them.
Clam shell: Complete 1-3 sets of 12 reps, resting 30 seconds between sets
Side leg lift: Complete 1-3 sets of 12 reps, resting 30 seconds between sets
Partial squat hinging at the hips: Complete 1-3 sets of 12 reps, resting 30 seconds between sets
Bridging with buttock squeeze: Complete 1-3 sets of 12 reps, resting 30 seconds between sets
Lunge walking: Complete 6 lunges with right leg leading, and 6 with the left leg leading
Forward lunge photos and instructions.
Figure 4 buttock stretch: Hold for 20 seconds each side, repeat 3x
Standing Hamstring stretch with neutral spine: Hold 20 seconds each leg, repeat 3x
Hip flexor stretch: Hold 20 seconds each leg, repeat 3x
Absolutely avoid crunches, sit-ups, double leg lifts, Russian twists, and “Supermans” as the risk for injury to the spine is just too great.
In summary, your progress will depend on your consistency over the initial 4-6 weeks, and listening to your body so you are not overdoing it. Keep doing the exercises and walking as part of your daily routine for the rest of your life to maintain the progress you have made.
McGill, Stuart. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. 2002
McGill, Stuart. Back Mechanic: the secrets to a healthy spine your doctor isn’t telling you. 2015
Bookspan, Jolie. Fix Your Own Pain Without Drugs or Surgery. 2006
Arnett, Jason. Breaking Down the Exercises that Break Down Your Spine. Spinal Research Foundation
This post written by Charlene Pilon