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Introduction to Neutral Spine
Neutral spine is the fundamental concept upon which your BackForever program is built. Neutral spine, in essence, means good posture as it relates to your back and neck. Neutral spine is the position in which your back and neck are placed under the least amount of stress and strain, allowing them to function properly without damage and therefore, without pain.
For people WITHOUT significant degenerative changes in the spine (most likely NOT you), ideal neutral spine looks like these pictures:
Note the natural curves throughout the spine in the body. These are ideal and are the positions in which your spine can do its job of supporting the body with the least amount of damage and pain. For most of you, it is likely that you already have significant degenerative changes in your spine, so your neutral spine may look a little different than this — but it will likely be very close. Don’t worry about it for now; we are going to teach you how to find your own unique neutral spine shortly.
Once you are able to find your neutral spine, you are going to learn how to move your arms and legs (hip and shoulder joints) without losing your neutral spine. Your hips and shoulder joints will move independently of your spine, allowing you to perform any and all movements and tasks without aggravating your back or neck.
This may sound difficult. At first, it can be difficult for some people. In time, this will become second nature. Keep in mind this is how humans are supposed to move. Your spine is a support structure upon which your arms and legs rely to move. Your spine isn’t supposed to move that much during most activities, especially not with load or in repetitive motions. If you think of a car, your spine is the chassis and your arms and legs are the axles and wheels. The chassis is meant to be stable, with movement happening in the axles and wheels. So it is with your spine, arms and legs.
Neutral spine is an integral part of relieving back and neck pain. We are going to train you in techniques that involve neutral spine, as follows:
- Teach you how to find your neutral spine, immediately relieving or lessening pain.
- Teach you to use your core (all of the muscles between your hips and shoulders, all the way around your torso) to lock your neutral spine in place.
- Build up endurance and strength in your core so that you can maintain neutral spine all the time in all activities and situations.
- Teach you how to sit, stand, and move in neutral spine.
- Apply this to any and all work, life, and sport related activities you do, for a permanent end to back pain and increase in fitness and health.
If you don’t quite get it yet, that’s OK. Read the next section and then you are going to watch a video demonstrating these concepts and guiding you through finding your own neutral spine.
CORE BRACING OF THE NEUTRAL SPINE:
This is step 2 of the process: learning to use your core to lock neutral spine in place. Let’s first define the Core. By core we mean all of the muscles between the shoulders and hips, all the way around your torso: front, back, and sides. Have a look at the Spine Encyclopedia to see some pictures of the core muscles. The core muscles’ job is to brace and protect the spine, allowing it to act as a stable foundation upon which your arms and legs can move. In other words, the core is there to brace and protect your neutral spine.
To allow the core to do its job, you lightly tense the muscles in your core to lock your neutral spine into place. By engaging or tightening these muscles, you brace the neutral position of your spine, locking it in place. You can then move safely and without pain or damage to your spine by moving the hips and shoulders while your spine stays in neutral.
Think of the muscles in your core as your body’s natural weight belt. Most of you have likely seen people in the gym with big belts around their waists, attempting to lift heavy weights. They have that belt on to stabilize their lumbar spines and protect their low backs. You don’t need a weight belt like that to protect your spine for day-to-day life, or even for moderately heavy lifting. You have one inside your body (your core muscles) that is there for this exact purpose.
The muscles in your core are there to brace and protect your spine, dissipating heavy loads safely throughout the body, keeping them from harming the spine and causing pain. The core muscles are made to STOP movement in the torso, not initiate or produce movement. Those muscles are there to stop the torque produced when moving or lifting from going into your spine and the surrounding structures. Once you learn how to turn this core brace on, you learn to move from your arms and legs (hip and shoulder joints) without losing your neutral spine.
Picture this now in your mind and wrap your head around it: your long term goal is to keep your neutral spine lightly braced all of the time while your shoulder and hip joints move INDEPENDENTLY of your spine. Learn to “wear” your body’s natural weight belt ALL OF THE TIME. Don’t worry, this easily becomes second nature in time. Once you learn it, your back won’t hurt — and if you forget it, your back will hurt. Pain is a powerful motivator and most people make this a habit quickly and effortlessly.
You are now going to watch a video that discusses neutral spine further, shows you how to find yours, and teaches you how to turn your core muscles on, bracing the core to protect and lock in neutral spine. Find a spot on the floor big enough to lie down on. Watch and rewatch this video until this makes complete sense to you. You don’t have to master the movement now, but you do need to fully understand these concepts. Read the text below and then watch the video.
FINDING YOUR NEUTRAL SPINE:
Lie on your back with your knees bent and your feet flat on the floor. Try to relax everything in your body and just breath. Start by performing a pelvic tilt.
To do that, just flatten your low back into the floor, and curl your tailbone upward. This is a posterior pelvic tilt. Now arch your back so that your low back comes off of the floor, and point your tailbone toward the ground. This is an anterior pelvic tilt. Now, slowly go back and forth between those two motions a few times. Find the position of your low back between these two extremes (flattening your back on the one hand and arching it on the other) that feels the most comfortable to you and stop there. Hopefully this is a position in which you feel no pain. If you can’t get to a pain-free position, that’s OK. Just stop where you feel the least pain. This is your neutral spine.
This is very, very important. Everyone’s neutral spine is a bit different, depending on the anatomical condition of their lumbar spine. For most people, there will be a gentle curve in the low back. For those who already have a disc bulge or related condition, their neutral spine might be a more arched lower back. For those with stenosis, their neutral spine may be a little more flattened than the one in that picture. Don’t worry about that. Whatever feels the most comfortable for you is your neutral spine for now. In time, your posture will improve. Start over and try to find it again. Practice several times until you feel comfortable with it.
Core Bracing with Neutral Spine
Now you must learn to maintain your neutral spine while moving your arms and legs. This means stabilizing the neutral spine by tightening or bracing your core. Pretend you are lying on the ground as you were when trying to find your neutral spine and someone was going to drop something light onto your stomach, like an apple or orange (as opposed to a bowling ball). What would you naturally do in anticipation of the apple falling on your belly? You would lightly tense or squeeze the abdominal muscles. Remember, it’s not a bowling ball so it only needs to be a slight contraction, not a full contraction. In time, you want to be able to easily carry yourself with a slightly tightened core all the time, maintaining neutral spine and good posture.
Steps for Neutral Spine with Core Brace:
- Lie on your back with knees bent and feet flat on the floor.
- Find your neutral spine again using the same technique mentioned previously. To test that you’re getting it right, put your hand on the insides of your hip bones — fingers pointing in and poking your belly, thumbs in the back. Now gently press inward into your abdomen.
- Lightly tense the muscles under your fingers. We’re trying to reach the muscles that are a layer or two down, not the ones you feel on the surface. The easiest way to tense these inner muscles correctly is to imagine that someone is about to drop an apple on your stomach.
- Now tighten the muscles under your fingers. This should only be about 20% of your maximum contraction.
- Now practice breathing without relaxing those muscles. As you breathe in and out, the tension in your abdominal muscles should stay the same.
Can you maintain a normal breathing rate while you contract those muscles? If not, you are probably using your diaphragm more than your abdominal muscles. Does your stomach stick out when you try to engage those muscles? You are bearing down too much (think being on the toilet and straining). Try it again. Practice breathing a few times while maintaining that abdominal brace. Practice this until you feel comfortable with it. The next step in this process is to start to move the legs while maintaining your neutral spine and core brace.
Slow March With Neutral Spine
- Find neutral spine.
- Engage the core.
- While maintaining core engagement, slowly lift one foot off of the ground moving from the hip joint, keeping the knee bent without letting your low back arch or flatten into the floor (if your neutral spine was already flattened into the floor that’s OK; just don’t push it harder into the floor when you do this.) If you can’t tell whether your back is moving, put a hand under your low back to see whether it moves when you do the leg movements. If you can’t do that because of a shoulder issue, ask a friend or loved one to help.
- Now return that foot to the floor. Here’s the hard part: When you switch from one foot to another, concentrate on not turning off your core brace. You shouldn’t feel a shift from side to side in the torso when you switch legs. If you did, reset and try again. Pain might also be your guide. It is possible that if you let go of your core brace while doing this, your back will hurt.
- Now put it all together. Try slowly “marching” back and forth without moving your low back.
This simple exercise is the key. It is imperative that you learn this and do it correctly. It is going to have a lot to do with solving your back pain.
- Does this hurt your back? If so, stop. Relax everything. Find your neutral spine again. Does that hurt? If it does, you likely aren’t in your neutral spine position. Keep going back and forth until you find a position that is more comfortable than the others. In time your back will be less sensitive and it is very likely that you will find a position that is completely pain free.
- If you can find a position for your spine when you are lying on your back that doesn’t cause pain or causes less pain (your neutral spine), then chances are extremely good that you can do this march without pain. With a little work, chances are extremely good that you can walk, move and go about your day without back pain. You may only be able to lift your foot an inch or so off of the ground in the beginning. That’s okay. Your stability and range of motion will improve as you develop more core strength and a better awareness of spinal stabilization. Always stay within your pain-free range of motion.
- Most people that can find a pain-free or more comfortable position when lying on their back will, in time, be able to achieve pain-free movements when standing. For some people this can take a long time. You are trying to change habits that you have had for decades. Success may not be accomplished in a day or a week. Practice this as much as needed today until you can do it with little or no pain or movement in your low back. You may have to stick with just this for a while. Most of you will not. Keep at it until you feel comfortable with it.
Creep is a very important, fundamental concept in regard to the spine which you must understand to fully appreciate the importance of posture. Creep is a property of the tissues in your back (discs, ligaments, muscles) that allows them to bend without breaking. After one of these structures such as a disc or ligament is subjected to a load for a certain period of time, creep sets in.
Load is anything that puts pressure on the tissues in and around your spine. This can be from your own body weight or additional weight from lifting objects, etc. For example: When you sit, a good deal of pressure is put through the discs in your low back and the muscles and ligaments around those discs. This is even more pronounced when you slouch.
These structures will resist that pressure for a certain period of time, about 20 minutes in most people, without bending or deforming. After about 20 minutes, creep will kick in and the disc will start to bend, like plastic, so that it won’t snap or tear. This is a good thing in that it keeps the disc from tearing. It is a bad thing, however, in that the disc is temporarily deformed and the joints associated with it are stressed more than they should be, which can cause inflammation and pain.
In addition, creep is happening in the muscles and ligaments around the disc, causing instability in and around the joint. This, in turn, causes the muscles to contract to an unhealthy degree to try to keep the disc from being overloaded, resulting in painful spasm in the muscles and thereby causing severe back and/or neck pain.
Finally, this laxity of the ligaments and muscles and resulting instability in and around the joint put you at a high risk for injury after you get up. It takes at least the same amount of time you spent sitting for the muscles, ligaments, and tendons to rebound to their former full strength. During this time of recovery, picking up something heavy or bending or twisting the wrong way can severely damage a disc or joint in your back.
As prominent spine researcher Dr. Stuart McGill noted, this has caused an epidemic of disc herniations in certain airports due to the baggage claim being too close to the arrival gates. People sit for hours on a plane, get up and only walk a few feet not allowing their discs and ligaments the necessary recovery time from creep, pick up a heavy suitcase and suffer a disc herniation.
Therefore it is best to prevent creep when possible and/or be careful after creep has set in to avoid further injury. Watch the video to learn how to prevent the damaging effects of creep.
STRATEGIES FOR COMMON SPINE-AGGRAVATING ACTIVITIES
Don’t underestimate how much the way you sleep can affect your back or neck pain. Spending around eight hours per day doing something is going to have a major affect your pain. The two main things to consider about sleeping are position and mattress.
Sleeping position: It is very difficult for most people to change sleeping positions. If you can, there is anecdotal evidence that sleeping on your back is best. This doesn’t work for everyone, though, so here are some tips. If you find that you feel hunched forward in the morning and have difficulty getting upright, you may have either a disc bulge or tight psoas muscles. In either case, you want to avoid sleeping in the fetal position with the knees bent. This shortens the psoas overnight and can increase forces into the lumbar discs.
If you have stenosis or aren’t sure and otherwise don’t like extension (back bending or neck bending backwards), then you will likely do better if you don’t sleep on your stomach.
Mattress selection: This is a tough one, but there are some general guidelines that work most of the time. For those that are curvy, voluptuous, or overweight, a softer mattress usually works better. This allows the bed to absorb some of the curves, keeping the spine relatively neutral. For very skinny people, a firmer mattress usually works better, allowing their spine to stay in neutral. For those in between, err toward a little bit firmer than softer. If you aren’t sure if your bed is having an effect on your pain levels, try a guest room, children’s bed, or hotel for a night or two. Do you notice any change (positive or negative) when you wake up the next morning or throughout the next day? If so, your mattress might be playing a role on your back or neck pain.
STRATEGIES FOR FLYING
Flying can be one of the most challenging activities for chronic back and neck pain sufferers. As you progress in your program, flying will automatically get easier. But you still need to be proactive when flying to avoid flare ups. Long flights will likely always be problematic for you unless you take these steps.
- Take a lumbar support and/or neck pillow with you. I don’t know why, but it seems that most airline seats have the opposite of what you would want for lumbar support. Always bring a pillow or support with you, especially for long flights.
- REMEMBER CREEP! You need to get up to avoid letting creep do its damage. Walk back to the bathroom at least every hour if you can (every 30 minutes if you are already hurting when you get on the plane).
- While you are back at the bathroom, take the opportunity to use the space near the bathroom to stretch and do some quick exercises to get blood flow into the muscles that support your spine:
- Stretch out your chest.
- Do some back bends (if you can tolerate them) and/or psoas stretches to try to reverse the hunched over position you’ve been in.
- Do some squats to get blood flow into the glutes and legs.
Driving is a lot like flying but usually not as challenging because you have more control over your position in the seat of the car and the amount of uninterrupted time you spend there. Here are some pointers:
- Use a lumbar support and/or neck pillow. If your car has an adjustable lumbar setting, try to replicate your neutral spine position with it.
- REMEMBER CREEP! You need to get up to avoid letting creep do it’s damage. Stop the car and get out every half hour if you can. If not, every hour at most. A trip to the bathroom or a walk around the car a few time can really help.
- If you stop at a bathroom, take the opportunity to use the space near the bathroom to stretch and do some quick exercises to get blood flow into the muscles that support your spine:
- Stretch out your chest
- Do some squats to get blood flow into the glutes and legs.
See pictures under “Flying”
Like flying and driving, the concept of creep plays a big role in spine-healthy work habits. You want to avoid staying in prolonged seated and/or standing positions. The best strategy for the office is to get an alternating sitting/standing desk. This is a standing desk which sits on top of your existing desk and has pieces which allow it so be raised to function as a standing desk, or collapses so that you can use it in a seated position on top of your normal desk. If you are able to put one of these in your office, alternate between standing and sitting about every half hour.
If you are unable to put an alternating standing/sitting desk in your office, the best posture for computer use is seen in the diagram below. Remember though, you don’t want to stay in this posture for more than 30 minutes. If you cannot get up and walk around for a few minutes every 30 minutes, then change out of good seated posture for a bit: slouch, lean to one side, cross one leg over the other. Then, return to ideal posture after a few minutes. To get blood flow into the right muscles and give your spine a break, you can use the same exercises as we suggested for driving and flying.
Returning to a pain-free sex life can be challenging, but is possible by implementing the concepts you have learned. In the beginning, when pain is still a common occurrence, the best position for many people is the Hands and Knees position for the partner with back pain, with the pain-free partner behind. The Hands and Knees position enables the partner with pain to find the neutral spine and use the core to lock it in, just like in the Hands and Knees exercises you have been doing. This position allows the other partner to brace the core and Hip Hinge without rounding and arching the back. The key to both is neutral spine. Try not to use the pelvis to create movement, instead relying on hinging at the hips. As your back and/or neck improves, other positions will become easier if you apply these same concepts.
Vacuuming is one of those household activities that can really sneak up on you and cause some damage. As you are probably starting to realize, the key is in how you move. The goal is to keep neutral spine and avoid twisting at the waist.
- Grip the vacuum handle with both hands to minimize placing too much force through one side. As you get stronger with some of your strength training exercises, one hand won’t be a problem anymore.
- Move the vacuum by moving your legs, not by pushing with one arm.
- Keep your spine still as you use your legs to move around the room.
Gardening can be very challenging. You have two ways to minimize the amount of strain you put on your back: 1. Break up the positions you’re in into small, manageable pieces. 2. Use hip hinge and gluteal engagement when in a bent forward position.
- Avoid standing and bending whenever possible. Get down on the ground by doing the opposite movement as you now do for getting off of the ground. Go into a half kneeling position first. Some of you may be able to accomplish some of your gardening work in this position. If so, switch knees every 15 minutes or so.
- A great position for short bouts is hip hinging from a kneeling position. As your core and glutes get stronger, this gets easier. Place pads under your knees if possible to prevent knee pain.
The opposite arm leg extension exercise, otherwise known as Bird Dog is one of the most commonly prescribed exercises for back pain. Unfortunately, it is also the one that is done the wrong way the most often.
The goals for this exercise are:
- Increased spinal stability when the spine is challenged from different directions with varying loads (your arms and legs).
- Increased engagement, endurance and strength of the back extensors including the lats.
- Increased gluteal engagement, endurance, and strength.
Instructions for Bird Dog:
- Get in the Hands and Knees position.
- Keep your neck in neutral with the rest of your spine. You should be looking at the ground, not in front of you.
- Go through the Cat and Camel positions to find your neutral spine.
- Lock your neutral spine in place by engaging your core.
- Slowly and carefully push one leg back, keeping your toes pointed toward the ground, pushing through your heel. Make sure not to arch your back, but keep the back still, in neutral spine.
- At the same time, slowly and carefully extend the opposite arm forward with your palm open and your thumb on top. Once your arm is fully extended, pull that shoulder blade back toward waistline. The muscles on top of that shoulder (upper trapezius) should not be contracted. The muscles behind and below your shoulder blades should be contracted.
- Hold for the appropriate amount of time.
- Switch arms and legs without moving the back.
- Do the appropriate number of repetitions.
- This causes neck pain. You are not using the muscles below and between your shoulder blades (lats and rhomboids). Instead, you are using the muscles on top of your shoulder blades (upper trapezius). Make sure that you set your shoulder blades in the proper Hands and Knees position before starting the exercise. Also, make sure you pull the shoulder blade of the extended arm back toward the waist. Finally, make sure you are looking at the ground and not out in front of you.
- This causes shoulder pain. Same as neck pain.
- This causes back pain. Make sure you are in neutral spine and that the core is braced. If this doesn’t help, you need to go to an easier version of this.
- My knees hurt on the floor. Add a pillow or pad if you have damaged knees. If this doesn’t work, try the modified versions for knee pain.
- My wrists hurt: See the section on wrist pain.
Wrist Pain: For those of you with wrist pain in the hands and knees position, try this modification. Use small dumbbells under your hands as shown in the pictures. This will relieve wrist pain in most people. You can also try wrist splints or braces with the dumbbells if they don’t work. When using the dumbbells, you will also need to compensate for the added height by placing a small step or other object of comparable size under your knees as shown.
Modifications for Knee Pain
For those of you with knee pain during exercises that require you to be on your hands and knees, we strongly suggest that you try cushions or pillows under the knees OR order knee pads, such as those used by volleyball players, to soften the pressure on the knees. Please try these tips first. If you try these and still have knee pain, we give you some alternatives for the hands and knees exercises.
Most of my friends close to my age have problems with their backs. Jeremy was one of the few chiropractors, trainers, or physical therapists who first analyzed the source of my problem and prescribed exercises that focused on minimizing the pain I was dealing with daily. I have always felt and believed that Jeremy’s attention to my issues were personal to me, and effective in order to help me live my life normally.
I have had serious neck stenosis issues for years and to put it simply: Jeremy has fixed me. A combination of neck and back strengthening exercises, patiently rolled out over time, has made the difference. He is extremely knowledgeable, thoughtful, easy to work with, and a great guy – [an] unbeatable combination!
Three years ago, I had back pain so bad I could not tie my own shoes. I was referred to Jeremy and went through his 5 step Protocol. After a few months of discipline and adherence to the program it completely solved the problem. To put it simply, he gave me my life back.