Wellness & Lifestyles Australia

POSTURAL EXERCISES & SPINAL HEALTH E-BOOK

prepared by

Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents Page No. IMPORTANT NOTICE ..................................................................................................... 2 

INTRODUCTION .......................................................................................................... 3 

SPINAL ANATOMY ........................................................................................................ 4 

IMPACT OF POSTURE ON SPINAL HEALTH ............................................................................ 7 

EXERCISES FOR THE NECK ............................................................................................. 10 

EXERCISES FOR THE UPPER AND LOWER BACK ..................................................................... 15 

SUMMARY ................................................................................................................ 20 

RESOURCES .............................................................................................................. 20 

CONTACT US ............................................................................................................ 21 

MANUAL LAST MODIFIED 18/01/2012

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IMPORTANT NOTICE The information provided in this document can only assist you in the most general way. This document does not replace any statutory requirements under relevant State and Territory legislation. Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the material contained in this document, which is provided on the basis that the Office of W&L is not thereby engaged in rendering professional advice. Before relying on the material, users should carefully make their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional advice relevant to their particular circumstances. To the extent that the material in this document includes views or recommendations of third parties, such views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its commitment to a particular course of action. © Copyright Australia 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved.

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INTRODUCTION Welcome to the W&L series of e-Books. You have chosen the edition on postural exercises and spinal health. This resource will be beneficial to Anyone who suffers from neck or back problems Anyone who wants to improve their posture to help prevent back and neck injury Anyone who would like to keep their spine in a healthy state and maintain a balance across their

joints The information provided is up to date and follows industry standard. W&L recommend that you continue to consult your physiotherapist so that your progress can be monitored and program tailored to your specific requirements.

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SPINAL ANATOMY

Figure 1: Bone anatomy of the spine

Diagram taken from:

Atlantic Spine Specialists, Spine Anatomy, accessed 18 January 2012 on http://www.atlanticspinespecialists.com/images/anatomy1.gif

Our spine is made up of 33 vertebrae stacked on top of each other. These can be divided into four main segments, the cervical, thoracic, lumbar and sacral (including coccygeal) regions. The shape of the vertebrae change slightly between regions to suit the different functions of each area. The cervical region has 7 relatively small vertebrae which are designed to allow quite a lot of movement – flexion, extension, rotation, lateral flexion). Most of the movement comes from the upper part of the neck. In a normal cervical spine there is a slight concave curve called a lordosis. The thoracic region is the 12 vertebrae between the neck and lower back. These are distinct from the other vertebrae as they also have ribs attaching onto them. The ribs act to limit the amount of possible movement, allowing only small amounts of rotation & flexion. The thoracic spine has a convex curve called a kyphosis. The lumbar vertebrae make up the last 5 vertebrae of the lower back. These are much larger due to the weight they have to support and mainly allow movements of flexion (bending forward) and extension (bending backwards) as well as a small degree of rotation. The lumbar spine, like the cervical, has a concave curve or lordosis. The sacral area consists of 5 vertebrae which are fused together (forming the sacrum) and fit into the pelvis.

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Figure 2: (a) Spinal cord & nerve anterior view & (b) Superior view

Diagrams taken from: (a)Spine Universe, accessed 18 January 2012

http://www.spineuniverse.com/sites/default/files/legacy-images/hs2fig5-BB.gif (b) Atlantic Spine Specialists, Spine Anatomy, accessed 18 January 2012 on

http://www.atlanticspinespecialists.com/images/anatomy1.gif

As the vertebrae stack on top of each other to form the spine, a canal is formed where the spinal cord extends from the brain. Between each pair of vertebrae are foramina where nerve roots project from the spinal, exit the spine and travel to all parts of the body. At each level, a nerve root exits on the left and right side.

Figure 3

Figure 3: Anatomy of an intervertebral disc

Diagrams taken from: Dr. Barrie Lewis, Chiropractic-Help, accessed 18 January 2012

http://www.chiropractic-help.com/images/IntervertebralDisc.jpg

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Situated between each vertebra (for the majority) is a sponge like disc. The disc helps to absorb force and assist movement in the spine. The disc itself is comprised of 2 layers – the fibrous annulus fibrosis and the gel like nucleus pulposus (see fig 3). Surrounding the spine to provide support to the bony structures and produce movement are many ligaments and muscles (see figure 4 and 5).

Figure 4: Example of spinal ligaments

Diagram taken from:

GiyabRadiology, accessed 18 January 2012 http://giyabradiology.blogspot.com/2011/05/spinal-column-anatomy-images.html

Figure 5: Musculature, deep and superficial, of the back

Diagram taken from: Build Muscle Abs, Get Off Balance! Instability Exercises Work Your Core, accessed 18 January 2012 http://www.musclebuildingrevolution.info/get-off-balance-instablity-exercises-work-your-core/

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IMPACT OF POSTURE ON SPINAL HEALTH As there are many structures that make up the spine, it is important to ensure that there is a balance in strength and movement between different levels and sides of the spine. This balance is best maintained when the spine is in a neutral posture - the position in which it works most effectively and where structures are under the least amount of strain. If the spine is not held in its neutral position, for example it is bent forward, bent backward or twisted, for prolonged periods of time, there are potential consequences. Not only is extra strain placed on the ligaments, joints, nerves and discs, both adjoining and within the spine, but the muscles surrounding the spine also have to work harder to provide support. A waterfall effect can result, with increased strain placed on peripheral joints, such as the shoulders, hips, knees and ankles, in addition to the strain on the central structures. A reverse process can also occur. Examples of this include over pronation at the ankles, leg length discrepancies and valgus (knock-kneed) or varus (bow legged) deformities of the knee. These changes in stress and loading at the peripheral joints can then cause discomfort, pain and altered stresses in the spine. Footwear can exacerbate these issues if shoes are in poor repair and provide poor support. High heeled shoes can also cause a change in the centre of gravity, which often presents as loading of the low back muscles with increased lordosis, again leading to pain and discomfort, especially if core stability and posture are also impaired. Common sagittal plane postural changes can be seen below (fig 6) showing kyphosis and lordosis alterations. Figure 7 demonstrates curvature in the coronal plane, known as scoliosis. Other changes in the spine such as spondylolisthesis or spondylolysis (a slip of one vertebra on another +/or fracture of the pars interarticularis), spondylosis (general degenerative changes within spinal joints) or spinal canal stenosis (narrowing of the spinal canal) can also cause the imbalances previously described. Additionally there are a number of postural changes specifically related to the aging process, including decreases in disc height, decreases in vertebral height (including due to wedge or crush fractures), and an overall decrease in soft tissue extensibility.

Figure 6: 4 types of postural alignment

Diagram taken from: Pilates Works 4 Life, Gotta’ Hunch? Part 4, accessed 18 January 2012

http://www.pilatesworks4life.blogspot.com/2008_04_01_archive.html

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Figure 7: Examples of scoliosis curvatures

Diagram taken from: National Institute of Arthritis and Musculoskeletal and Skin Diseases, Q&A about Scoliosis in Children and Adolescents,

accessed 18 January 2012 http://www.niams.nih.gov/Health_Info/Scoliosis/default.asp

In the short term, muscle imbalances from altered posture can result in pain and discomfort through local spasm, strain or fatigue. In the long term, these resultant stresses can combine to cause permanent soft tissue damage and pain, as well as decreased performance of the joints and soft tissues. Other permanent changes include joint degeneration (osteoarthritis with pain, stiffness and decreased joint range of movement), disc damage (bulge, prolapsed including nerve and muscle symptoms), muscle shortening or rupture and local nerve impingements/entrapments. To help prevent these consequences, poor posture can be improved by completing strengthening and stretching exercises which will increase muscular support and improve balance to the spine. How do you know if you have a muscle imbalance, joint stiffness or disc injury? The most common way in which people become aware of these issues is the development of pain. A physiotherapist can check for appropriate neutral positioning of muscles and joints to ensure there are no muscle imbalances - whether in power, lengthening or shortening of muscle groups. Joint stiffness is noted through individual awareness and again your therapist can check for decreased range of movement, localised joint or segmental stiffness. Conversely, your therapist can also assess whether a client exhibits range over and above the usual. This increase in movement can in turn cause pain by overuse of the joint and decreased stability. Acute back injuries can include muscle, joint, nerve (including spinal cord) or disc injuries. They may present as pain, swelling, altered movement/lack of movement, muscle weakness or numbness, depending on the pathology. In these cases it is important to see a medical practitioner and/or physiotherapist to determine the best management options. As a general rule, muscle and soft tissue pains present as an ‘ache’ or ‘stiffness’, muscle spasm may result in a ‘stabbing’ presentation of pain. Nerve issues are often characterised by unusual sensations such as burning or pins and needles. Sharp pains can often also occur with nerve injuries. Physical signs include weakness, altered or decreased sensation to pressure or temperature, depressed reflexes.

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Addressing the problem The most common way to address these problems is through a stretching and strengthening program. Short muscles are stretched; weak muscles, whether short or long can then be strengthened. Any client with a back injury is also likely to have altered core stability (figure 8). This refers to the back extensors (multifidus and erector spinae), the low stomach muscles (transversus abdominus), the diaphragm of the lungs and the pelvic floor. The transversus abdominus especially are effected in the long term after a back injury and commonly require targeted retraining. Usually the use of the transversus abdominus is an unconscious action and this may cause active retraining to be more difficult. In difficult cases, real time ultra sound (RTUS) can be employed to provide the client with an increased level of feedback.

Figure 8: Muscles and structures making up the body’s “core”

Diagram taken from: Physio Works, What is your core stability?, accessed 18 January 2012

http://www.physioworks.com.au/treatments-1/core-stability-exercises

In rare cases neck or back supports or braces can be used to help provide support. Usually these are used in acute instances and at medical request. Prolonged use of bracing can actually cause a worsening in the pathology due to muscle wasting (the brace does the work, not the muscles) and thus further undermine joint support.

Transversus abdominus

Multifidus & Erector spinae

Diaphragm

Pubic symphysis

Sacrum

Pelvic floor

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EXERCISES FOR THE NECK The following exercises should be performed with caution to pain and in consultation with a therapist if you have concern with any of these exercises. Stretching: upper trapezius – To stretch the left side, bring your right ear to your right shoulder then turn your head to the left (looking upward). Look down towards your left armpit and reach your left hand towards the ground/behind your back. Hold for 30 seconds and repeat 3 times. Repeat to stretch the right side.

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Stretching: levator scapula – To stretch the left side, bring your right ear to your right shoulder and then turn your head to the right. Look down towards your right armpit and reach your left hand towards the ground/behind your back. Hold for 30 seconds and repeat 3 times. Repeat to stretch the right side.

Stretching: side tilting – To stretch the left side, bring your right ear to your right shoulder, assist using your right hand. Hold for 30 seconds and repeat 3 times. Repeat to stretch the right side.

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Stretching: turning – Turn to the left, using your left hand to gently push your right cheek. Hold for 30 seconds and repeat 3 times. Repeat to turn to the right side.

Stretching: forward nodding – Have both hands behind your head. Tuck your chin in and look down towards your chest and use your hands to help gently. Hold for 30 seconds and repeat 3 times. Stretching: upper aspect of the neck – To stretch the left side, place your left hand on your chin and right hand on top of your head. Use your left hand to push in your chin and then use your right hand to pull your head forward and slightly off to the right. Hold for 30 seconds and repeat 3 times. Repeat to stretch the right side.

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Strengthening: Head retraction – Poke your chin forwards and curl your neck. Work the muscles which pull your head back on top of your neck and tuck your chin in. Pull your shoulders away from your ears. Hold for 5 seconds and repeat 10 times.

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Strengthening: Head retraction lying down – Lie on a pillow and tuck in your chin. Keep your chin tucked and squash the pillow with your head. Hold for 5 seconds and repeat 10 times.

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EXERCISES FOR THE UPPER AND LOWER BACK Strengthening: Retraction of scapulae - Whilst maintaining your neck and back in a neutral posture, concentrate on drawing your shoulder blades backward and together. Hold for 10 seconds and repeat 10 times. Ensure you feel the contraction relax between repetitions. If you can not, try holding for a lesser period of time until you can feel yourself relaxing at the end of the contraction. Avoid actively moving your arms when doing this exercise. Strengthening: Depression of scapulae - Whilst maintaining your neck and back in a neutral posture, concentrate on drawing your shoulder blades downward and together. Hold for 10 seconds and repeat 10 times. Ensure you feel the contraction relax between repetitions. If you can not, try holding for a lesser period of time until you can feel yourself relaxing at the end of the contraction. Avoid actively moving your arms when doing this exercise. Stretching: Upper back stretch – Reach arms above head and hold hands. Squeeze your shoulder blades down and back. Use your abdominal (stomach) muscles to prevent your lower back arching. Hold 20 seconds and repeat 5 times.

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Stretching: Back rotations sitting – Sit on the floor with your right leg crossed over your left. Turn to the right and push on your right knee to increase your stretch. Hold 20 seconds and repeat 5 times. Repeat in the opposite direction.

Stretching: Back twists lying – Lie on the floor with arms out to the side and knees bent up. Cross your right leg over your left and let your knees drop over to the left side. Reach your right arm out away from your body to increase the stretch. Hold 1 minute and repeat going the opposite direction.

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Stretching: Prayer stretch – Position yourself on all fours and then sit back onto your heels. Reach your arms out in front and hold for 30 seconds. Crawl your hands over to the right side to stretch out your left side and hold for another 30 seconds. Crawl your hands over to the left side to stretch the opposite direction.

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Back extensions – Prop on your forearms whilst lying on your stomach to maintain the extended position in your low back. Hold the position for 30 seconds, rest and repeat 3 times. Back curls – Lie on your back and curl your knees to your chest. Relax in this position for 20 seconds. Draw small circles with your knees 10 times and repeat in the opposite direction.

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Strengthening: Transversus abdominus - Whilst lying on your side, draw your belly button in toward your spine. Hold it for a count of 10. Make sure you can feel it relax at the end of the contraction. If not try to maintain your hold for a smaller length of time until you are able to feel the contraction relax. Do not hold your breath – if you are, you are not activating the correct muscles. To progress this exercise, undertake the exercise in sitting, standing and whilst moving. Aim to complete 2 sets of 10 repetitions, each with a 10 second hold. Strengthening: Pelvic Floor - The pelvic floor is made up of a sling of muscles stretching from the pubis and pubic rami anteriorly to the coccyx posteriorly in gross terms. As such it controls both urethral and anal outlets. Strengthening is by drawing the pelvic floor “up” – recreating the feeling of ‘hanging on to get to the toilet’ or ‘stopping yourself passing wind’. These exercises can be undertaken for both strength and endurance. Strength: repeat the drawing up feeling 20 times quickly Endurance: repeat the drawing up feeling 10 times, for 2 sets, holding each one for 10 secs (ensure you feel the muscle relax at the end of each contraction).

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SUMMARY In summary, the spine is a complex structure made up of many components which work together to allow the spine to move efficiently. Through bad posture or injury the spine can be strained and structures become unbalanced. By doing exercises which strengthen and stretch the various components of the spine, support can be increased to improve spinal health. Please use this resource as a guide to your exercises in consultation with your therapist. All the best for a strong and healthy spine, The W&L Team

RESOURCES

Sports Med booklets on postural exercises for neck and upper back, and neck exercises were

referred to for the content of this e-book.

Better Medicine, Rich Klasco, M.D., FACEP (2011), Spondylolsis,

http://www.bettermedicine.com/article/spondylosis

American Academy of Orthopaedic Surgeons, Pediatric Orthopaedic Society of North America

(2007), Spondylolysis and Spondylolisthesis, http://orthoinfo.aaos.org/topic.cfm?topic=a00053

Spine Universe, Stewart G. Eldelson, MD (2010), Spondylolisthesis,

http://www.spineuniverse.com/conditions/spondylolisthesis/spondylolisthesis-0

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CONTACT US Wellness & Lifestyles Australia 2/59 Fullarton Road, Kent Town SA 5067 P: +61 8 8331 3000 F: +61 8 8331 3002 E: contact@wellnesslifestyles.com.au W: www.wellnesslifestyles.com.au www.wleducation.com.au W&L services include: Physiotherapy Aged Care Funding Instrument (ACFI) Consultancy Podiatry Speech Pathology Dietetics Diabetes Education Occupational Therapy Psychology Physiotherapy Aide Diversional Therapy Aromatherapy Natural Therapies Massage Exercise Physiology Educational Training Staff Wellness Program Locum Services Medicare Billing Aged Care Funding Instrument Documentation Online Training W&L products include: Posters E-books E-learning modules Audio/visual Hot tips/articles