Are you sitting comfortably?

Posted by Nell Mead at 12:00 on 22 Mar 2013

"This is great!  Can I just sit here for the next hour?" That's a question I hear several times a week, as newcomers to Victory sink into the rocking chair in my treatment room.

Why a rocking chair, I hear you ask? Well, to answer this, we have to go back to the principles of what backs like, and what they don’t.

You have 29 bones in the spine, of which 24 move freely. You have 23 intervertebral discs (there’s no disc between C1 and C2, just below your skull). Spines are designed for movement, not for staying still for long periods.

As I’ve blogged before, discs are built a bit like rubbery doughnuts, with a thick, tough outer ring (annulus fibrosus) and a more jellylike centre (nucleus pulposus). The nucleus is supposed to bear most of the weight, but this can only happen if there’s enough fluid in it – otherwise it flattens down, and you end up weight bearing through the annulus, which can lead to degeneration and pain. We can encourage fluid to flow into the nucleus if we regularly alter the pressure on the disc, leaning back and forth to stretch and squash different areas. Conversely, if we stay still for too long, even if we have “perfect posture”, the disc gradually compresses, with fluid draining out faster than it can flow back in.

The amount of pressure going through the discs is important – discs don’t like being put under sustained high pressure. Factors that increase pressure through the discs include:

• Your back muscles. The muscles that support the back have vertically oriented fibres. So when you make them work (for example, carrying heavy objects, or sitting unsupported), they compress the discs. They also compress the discs when they are in spasm, which is a normal response to pain. Spasm is when the muscles get stuck in a shortened position, and this will obviously exert increased pressure on the discs.
• Posture. Alf Nachemson's team published a study in 1981 whereby volunteers had pressure transducers inserted into their spinal discs, and, the level of pressure was measured in a variety of different postures. The lowest pressure was recorded when the subjects were lying flat, and the highest when they were bending and twisting (in this position, disc pressure was 400% more than when standing straight). Although this research is relatively old, it’s sound - and we can't reproduce the tests today because no ethics committee is going to approve the non-therapeutic insertion of pressure transducers into healthy discs these days! Much too risky.
• Excessive loading. This largely means carrying heavy objects, though there is some evidence to suggest that being significantly overweight may also contribute to back pain.

It is normal for fluid to drain out of the discs during the day (it’s common to be a centimetre or two shorter before bed, than you are when you wake up, because fluid flows into the discs overnight when you’re lying down and relaxed) but the more you can reduce this, and keep the discs hydrated during the day, the less likely you are to suffer from disc-related back pain.

So, how do you encourage the discs to keep hydrated? There’s a lot that you can do!

• Reduce the amount of time that you spend sitting down – get up and move and stretch. Big movements such as toe touching and using the back block cause significant pressure change across the discs, encouraging fresh fluid to flow in.
• When you are sitting, make sure you are supported, especially if you have back pain. This reduces the work the back muscles have to do - and thus reduces the compressive forces produced by those muscles. Nachemson's study showed reduced compression in people who sat supported (compared to standing upright, pressure was reduced by 40% in people who sat back with support) compared to those who sat without support (compared to standing upright, unsupported upright sitting actually increased disc pressure by 50%, and unsupported slouching increased disc pressure by 75%).
• Drink plenty of water. This is what keeps the nucleus plumped up; but it can only flow into the disc if it’s freely available in your body!

So, with the theory out of the way, I think rocking chairs are helpful to prevent excessive sustained loading in the discs because:

• Whether you sit back or sit forwards, the back of the chair follows you and provides some support – thereby reducing the amount of work the muscles have to do to support you: reducing pressure.
• They keep you moving: I defy anyone to sit still on a rocking chair for a long period. This keeps altering the pressure across the disc – admittedly, not nearly as much as it alters if you have a really good stretch; but still, it’s a help.
• They encourage you to sit back, which as we know decreases disc pressure by 50% compared to standing.

In summary, to keep your back as healthy as possible, I encourage you to find a chair that moves with you, rather than one that tries to hold you still. The comfy ones we use in Victory are the Ten Two (modelled above by The Back Shop’s Alan Sameiro) and the RH Logic 400 (which looks more like an office chair, although the rocking mechanism is the same as in the Ten Two) – but other models are available. The Back Shop (and their parent company, Back in Action) offer seating assessments and help you to find the most appropriate chair for you.

And if you’d like any more advice on how to fix your back, or how to sit comfortably, come on in and let us have a look at you, and give you some individual advice.  Contact Sarah Harvey to arrange your appointment now!

Sports massage: not just for sportspeople!

Posted by Nell Mead at 12:00 on 3 Sep 2012

Monday mornings are team training mornings at Victory - where we get together to discuss theories and injuries, and practise specific techniques on each other.  Last week I took this picture of new sports massage therapist, Helen Murawska, practising on Sarah Franklin.

Helen then got thinking about sports massage and what it's all about - and this blog post is the result.

For all of us, regardless of what we do, daily living means wear and tear on certain structures in the body. From hairdressers who spend all day standing, with arms constantly raised and scissors in hand, to office workers who spend at least 8 hours a day sitting at their desk, hunched over the keyboard. Postural demands cause postural changes! The muscles that have to work overtime tend to pull the underlying structures (such as the pelvis, or the shoulder blade) into that position to make their life easier. The muscles that don’t ever really get asked to work tend to switch off, and allow those underlying structures to be moved more easily. Hence postural changes occur.

This is your body’s way of trying to make things easier for itself… it becomes familiar with the posture you adopt the most and makes the necessary changes to keep it that way.  If you were going to spend 24/7 in that posture, happy days! But (luckily) we do get some time off to go for walks, gym, swim, shop, anything other than work…… This is when we face problems and unfortunately, it is when we are on our ‘down time’ away from the job that we notice niggles and aches and pains. Why? Because we are now demanding different postures from our body. We are standing upright and extending the lower back which normally lives in flexion - or, conversely, sitting slouched in front of the TV when our backs have become stiff to help us stand up all day.

Here’s where we can help. Sports massage (as opposed to relaxation massage) helps to ‘turn down the volume’ on those tight muscles that have been working overtime, lengthen tissues that have become short and ‘stuck’ from never being used, and realign structures that have become asymmetric. Because we at Victory like to go that bit further, we will also give you and specific stretches to keep you mobile enough to be able to adopt any posture you need to, and specific exercises to help turn on those muscles that haven’t been used for a while, in order to be strong enough to hold a position when necessary.

In four or five sessions from us, and with a bit of commitment from you, you can be rid of aches and pains that you may have had for months or years but haven’t done anything about yet. DO SOMETHING ABOUT IT TODAY!!

If getting rid of your niggles sounds good to you, why not book an appointment with Helen?  You can either contact us here, send her an e-mail - or call her on 07932 175903.
 

The bending myth

Posted by Nell Mead at 19:08 on 24 Aug 2012

If I hear someone saying “bend your knees, not your back!” once more, I think I might scream. Why? Because it’s just so wrong, and so counterproductive.  Think about it. You have 29 bones in your spine (7 in your neck, 12 in your thorax, 5 in your low back and 5 – mostly fused – bones in your sacrum). Given that the sacrum is mostly fused, you have 20 movable, functioning, weightbearing joints in a normal, healthy spine: from L5/S1 at the bottom, where your low back meets your pelvis, to C1/C0 at the top, where your neck meets your skull. Each joint is cushioned by discs made of spongy cartilage, and controlled by ligaments and muscles.

These ligaments and muscles combine with the shape of the bones to allow you to bend in all directions: forwards, backwards and sideways; and to twist and rotate, and to perform all these movements in an infinite variety of combinations. And – as we’ve said before – if you don’t use these movements regularly, and flamboyantly, you’ll lose the ability to do them properly, and this loss of movement is frequently a precursor to injury, as the stiffer and less conditioned to movement you are, the less able your body is to roll with the punches and cope with unexpected movements. In which situation, your spine might just as well be one long bone, rather than being a chain of little movable ones.

The biggest movement most people’s spines are able to produce is flexion, bending forward towards your toes. This is a function of the shape of your spine: to flex, each upper vertebra has to tilt forward on the one below it, squashing the disc at the front and stretching it at the back. The back of the disc (made of the same substance as ligaments) is designed to stretch by up to 90% to allow this movement to happen. Simultaneously, the facet joints at the back open out and their joint capsules (also made of the same substance as ligaments) also stretch.

The bit about ligament tissue is important, because it’s by stretching ligament (for short periods, and with a force less than that required to take it to its elastic limit) that it responds by building more tissue and getting stronger. If you don’t stretch it, it gets weak. And that’s why it’s so wrong to avoid bending: if you avoid bending, you’ll weaken your back.

However, the conventional wisdom is that flexion – particularly combined with rotation – causes your discs to herniate. That’s partly true. It’s true of people who have weakened their backs in the first place - either by not routinely bending (so they become stiff and weak), or by bending or slouching for prolonged periods (in this case, instead of becoming stronger, the discs and joint capsules become overstretched and weak). Also, because lots of people have heard the “bend your knees, not your back” mantra, they become scared to bend – something that can actually make back pain worse, because if you have back pain, avoiding bending can lead to a chronic pain pattern with central nervous system hypersensitivity – much harder to treat than the original back pain issue!

Clearly, therefore, some bending is safer than others, so – particularly for people who are new to bending – here is Helen Murawska showing us how Sarah Key teaches us how to bend.

• First, stand straight, with your weight evenly through both feet.  Pull your tummy in and lift up your pelvic floor. This increases the pressure in your abdomen, which helps to stabilise your spine and minimise unwanted shearing forces.

• Curl your pelvis underneath you. This slightly tensions your multifidus muscle, which is another key stabiliser of the spine. It also pushes your knees into a slight bend, which minimises any stress through the knees and hamstrings. Sarah calls this “pre-humping” your spine.

• Walk your hands down your thighs and then down your shins. Keep your tummy pulled in.

• Once you’ve walked your hands as far down your shins as you can, let your hands dangle for a few seconds and drop your head, completely relaxing your neck.  I call this the "gorilla pose".  Check that your pelvic floor is still switched on, and that your tummy is tightly pulled in.

• To come back up, push your knees forward, then your hips forward, and uncurl your back, bringing your head up last. This should be a sinuous movement, like a wave passing through your body.  When you get to the top, check once more that your pelvic floor is still switched on - and then relax.

To keep a strong spine, we should all be doing this every day. And it’s how I think we should lift relatively small, everyday loads. It's not how we should be lifting Olympic weights, but this is how I get peas out of the freezer, and how I pack my laundry into the washing machine.

If you have back pain when you bend, try this way of bending instead.  But if you're not sure, or if you still have back pain, do come on in and let us work out what's wrong and how to fix you - you can book an appointment here.
 

Shakespeare? What a pain!

Posted by Nell Mead at 15:48 on 19 Nov 2011

I was lucky enough taken to the Old Vic recently by an old friend, to see Kevin Spacey playing the lead role in Sam Mendes’ production of Richard III. I’m not generally a huge Shakespeare fan (memories of watching Macbeth at the National Theatre when I was studying it at GCSE put me off somewhat; and I found Jacobi’s Lear unconvincing this summer) nor am I a particular Spacey fan; but this show really blew me away. I was enthralled and barely glanced away from the stage for the entire three hours.

But three hours is an awfully long time for a man to play a twisted hunchback; the King is rarely offstage and the physicality of Spacey’s performance was quite extraordinarily compelling and consistent. He played a man in pain extremely convincingly; in fact I’d be amazed if he wasn’t genuinely in quite some significant pain by the end of the production, and I wonder if I was the only audience member relieved to see Richard hoisted aloft by his ankles at the end: at least he finally got some traction to relieve his poor, tortured spine!

After all, Kevin Spacey wouldn’t be the first actor to be left crippled by Shakespeare. I rather assume this story is apocryphal, or at least that the wording has been altered over the years; but according to Antony Sher’s “Year of the King”, at the end of the original production of Richard III, Burbage told Shakespeare “If you ever do that to me again, mate, I’ll kill you.” Somewhat later, in 1972, Robert Hirsch of the Comédie-Française apparently found some sort of solution: his Richard limped on alternate legs from night to night!

Simon Russell Beale managed a five-month run as Richard III in Mendes’ production for the RSC in 1993; but just three days after it transferred to the Donmar Warehouse, he was forced to retire and to have an operation on a prolapsed spinal disc. The same thing happened to David Tennant in 2008 during a run of Hamlet: after a successful summer run in Stratford-upon-Avon, the production moved to the Novello Theatre and Tennant ended up in surgery.

Given how slowly spinal discs go wrong, it seems unlikely that Shakespeare and his directors can be completely blamed for this spate of injuries to leading men. They probably had some degree of back pain before they took up their roles. However, there’s no doubt that the physical demands of playing a role which requires extreme postures to be maintained for prolonged periods, will cause a degree of soft tissue deformation and also of extreme concentrations of compressive stress on the spinal discs. Moving and changing position regularly causes compressive stresses to alter, and it is thought that this assists with disc nutrition (which is why it forms the basis of Sarah Key’s “pressure change therapy” theory); the reverse is also true, with prolonged relatively static postures, particularly extreme postures, effectively reducing the discs’ nutrient supply and causing damage.

So my pleasure in watching this extraordinary production was tempered somewhat by the thought of the damage the leading actor was doing to himself in his effort to provide a superb experience for the viewing audience. Mr Spacey, I do hope you have a good physio!
 

The problem with leg raises

Posted by Nell Mead at 09:50 on 3 Aug 2011

I went to my usual circuit training session the other day, run by British Military Fitness.  It's a lot of fun: a fairly tough workout with a lot of cameraderie and competition, and outwardly no-nonsense (but actually very humorous) instructors.  They will push you as hard as you want to be pushed, and often very slightly harder.

I love the sessions; but as a punter, you have to remember that most instructors aren't psychic. They will always ask if you have an injury, and will always offer alternative exercises, but they can only help you if you tell them that there is a problem.  This is something that can be tricky unless you are quite confident in your own body and its capabilities (not something I generally struggle with too much, but I've had a lot of practice!).  It's easy to let your competitive side take over, and to start competing in exercises you're not familiar with.  Consequently your form can go to pot as you try to complete that 20th rep before the guy next to you: if you're doing a demanding exercise, that's an easy way to get injured.

One of the exercises I really dislike in that situation is the leg raise, where you lie on your back with your feet together and wave your legs in the air, with an obtuse angle at the hips.  It's an exercise that's supposed to work the lower abdominals and tone the tummy.

The reason I dislike this exercise so much is that the majority of people find it tough to control their torsos in this position.  I have a strong back and good awareness of trunk control, but in this position I find it really hard to stop my low back from arching.  That's because the hip flexor muscle psoas major is being put under a lot of stress to control the momevent of your legs at the hips.  Psoas starts at the sides of your lumbar vertebrae (T12 to L5 to be precise) and goes down to the lesser trochanter of the femur.  When it contracts, these bones are pulled together.

When your back is being correctly stabilised (by, among other muscles, lumbar multifidus and the deep abdominals), the spine is braced to pull your femur forwards and up, so your hip flexes and your legs move up and down.  That's the plan; so far, so good. 

But when your back isn't correctly stabilised - either because of weakness or pain around the low back, or because you're focusing on banging the numbers out rather than on protecting your back properly - your low back can arch and the vertebrae shear forwards towards your hip rather than your hip moving towards your spine in a controlled manner.  I've mentioned forward shear as a bad thing before, when I talked about spondylolisthesis.  So with 80% of the population suffering from back pain at some point during their lives, I'd suggest avoiding this exercise if possible, not because it is intrinsically bad but because many people will do it badly, particularly in a competitive setting.

A good alternative exercise, which will strengthen the deep abdominals safely, is the reverse curl.  Lie on your back with your hips flexed to 90 degrees.  Your knees can be bent or straight, but your hips must not drop below 90 degrees throughout the exercise.  Using your abdominal muscles, pull your legs towards you so that your bottom lifts off the ground.  Hold for a second, then lower it slowly back to the starting position.  If you feel that your back wants to arch as you return to the start, try putting your hands or fists under your bottom (not your back) as this will encourage you to keep your low back in contact with the ground at all times.  This way you will still be working your lower abdominals and your psoas, but there will be no risk of a shearing force damaging your back.

I should mention that after quietly explaining my concerns about this exercise to the excellent BMF instructor, she asked me to show the class and to post about it on the BMF Facebook page.  So Annie, this one's for you!

Knees and pelvises - what to do about them

Posted by Nell Mead at 15:13 on 14 Jul 2011

In my last post, I explained how having a stiff and unyielding pelvis can be a real pain in the knee.  But it's not fair to leave you hanging, so here's the solution.

The first step is to release the tightness in the low back and pelvis joints.  To do that, you need to release the surrounding muscle spasm and then stretch out the muscles and ligaments that are holding the joints so stiffly.  This will help to flush out the joints, encouraging the synovial fluid inside them to become more liquid and less viscous, allowing more nutrients in and more waste products out.

At Victory, I release the low back and pelvis joints using my feet, in line with the Sarah Key Method.  This is quick, effective and quite gentle, and it gives a "kick-start" to the exercises, which allow you to maintain and improve on the changes we achieve in the treatment session.  However, in many cases it is also possible to make significant gains with just the exercises.

Therefore, for home treatment, the two exercises I really recommend to release the low back and pelvis are the appeasing exercise and a variation on the back block exercise.  Alternate them, doing three sets of each exercise for 30 seconds each, 2-3 times per day, and your pelvis should soon start to free up.

The variation on the back block exercise is that instead of placing the block horizontally under your pelvis, this time I'd like you to place it vertically - so that it points down towards your feet.  The upper end should still be under your pelvis though, not under your low back.  Then, once you've lowered your bottom onto the block, instead of sliding your feet away from you, just drop your knees apart, something like this picture from the Egoscue website.  If your adductors (inner thigh muscles) are tight, you may well feel a stretch there; if they're loose, you'll feel a stretch at the back of your pelvis as the "wings" stretch apart.  Hold the position for 30 seconds before drawing your knees back together, removing the block from under your pelvis, and resuming the appeasing exercise.

The second step is to stretch your hamstrings, with particular emphasis on the distal (knee) end.  Traditional hamstring stretches, where you bend forward with knees straight, focus on the proximal (hip) end of the muscle; but people with knee pain tend to be tighter near the knee. 

To emphasise the distal end of the hamstring, you need to start with your hip fully flexed, and then gradually extend the knee.  So, as demonstrated here by the lovely Graeme, stand in front of a chair (preferably one without wheels!) and place one foot on the seat.  Bend forward at the torso and get your chest right onto your thigh.  Hug your thigh tightly with both arms, so that your chest stays attached to it throughout the stretch.

Gradually lean your bodyweight backwards so that your raised knee starts to straighten out.  Go as far as you can, until you feel as though your chest wants to lift, then hold the position for 10 seconds.  Release slightly and then lean back into the stretch for a further 2 x 10 seconds, then repeat with the other leg.

Another really useful treatment is massage.  You may well find that you have tight, sore trigger points in your buttocks, hamstrings, adductors and/or iliotibial bands (fascia that covers the outer thighs).  Stretching can be significantly aided by massage to get rid of these small localised areas of muscle spasm.  You can either get someone to help you with this (if your helper is not a trained therapist, ask them to start gently and work their way in: kinder and more effective than an aggressive pounding!) or you can self-treat using a foam roller.  I really like this comprehensive YouTube video from Alex Poole that shows some effective foam roller techniques.

If you would like to get rid of your knee pain (whether due to the pelvis or not!) please e-mail me to arrange a session and see how I can help you.

Dem bones, dem bones... Knees and pelvises

Posted by Nell Mead at 14:00 on 20 Jun 2011

Dem bones, dem bones, dem dry bones

Dem bones, dem bones, dem dry bones

Dem bones, dem bones, dem dry bones

Hear the word of the Lord

Toe bone connected to your foot bone

Foot bone connected to your ankle bone

Ankle bone connected to your leg bone

Leg bone connected to your knee bone...

OK... you've probably heard a verson of James Weldon Johnson's spiritual somewhere before, and while it's not technically accurate in its anatomy, the concept (that everything in the body is linked and works together, rather than a body being a collection of separate joints) is one I reference a lot.

Today I'm going to talk about the link between knee pain and your pelvis - or, as JWJ might have put it, your knee bone's connected to your back bone.

The large muscles of the thigh - quadriceps at the front, and hamstrings at the back - are biarthroidal muscles.  This means they cover two joints, the hip and the knee.  The quadriceps work to flex (bend forward) the hip and extend (straighten) the knee.  The agonist (opposing) hamstrings work to extend the hip and flex the knee.  Both groups of muscles attach to the pelvis at the top, and to the shin (tibia and fibula) at the bottom.

When you walk, and more violently when you run, your quadriceps pull to swing your leg forward, as your hamstrings pay out at a controlled rate to prevent you from hyperextending and jarring your knee, facilitated by a slight backward rotation of the sacroiliac joint in your pelvis.  As your foot lands, both the quadriceps and the hamstrings contract to control your landing, and then the hamstrings begin to pull to provide the power to propel you forward over your landing foot.

So far, so good.  Everything is working normally; and normal functioning of joints with no structural deficits will cause no pain.  But what happens when there is a glitch somewhere in the system?

The sacroiliac joint of the pelvis (between the sacrum at the base of the spine and the iliac "wings" of the pelvis) is a pretty common source of problems.  There are many reasons why the sacroiliac joint can stop functioning properly - ranging from an impact injury such as a car crash or a fall, to a general poor posture which involves staying too still and not using the joint enough - but the effect generally is that it stops rotating effectively.  When this happens, it impacts on the hamstring's ability to pay out in the swinging leg, and the joint's ability to absorb shock when the foot lands.

When the hamstring doesn't pay out effectively, your body will respond by altering your gait so that it doesn't have to.  You'll take ever-shorter strides and your running gait will alter from a smooth glide forward to a jerky bob-up-and-down movement, which requires more shock absorption from the sacroiliac joints... and thus the cycle is perpetuated.  And if the sacroiliac joints can't absorb shock properly - well, the shock of impact has to be absorbed somewhere, and the knee (particularly the patellofemoral or kneecap joint) is often the victim.  In my experience, this is a very common cause of knee pain, especially in runners.

What can you do to break the cycle?  You need to reverse it: get your pelvis moving, and your hamstrings flexible.  I'll explain how in my next post, so watch this space!

If you are struggling with knee pain when you run, it may well be linked to a dysfunction at your pelvis.  Please contact me for assessment and treatment.

Mobilising the Military

Posted by Nell Mead at 18:58 on 17 May 2011

Today I took a trip to Hampshire to demonstrate the Mobiliser bed to some military medical personnel. 

As I've previously mentioned, in 2004 I designed and carried out the first piece of formal research on the Mobiliser bed, a passive spinal mobilisation device created by engineer David Newbound, the owner of the Back in Action chain of ergonomic furniture shops.  My pilot study bore out the manufacturers' claims that the Mobiliser could help to improve range of movement in the spine, improve thoracic expansion and reduce pain levels in patients with back pain - and I've been using the Mobiliser ever since.

Finally, it looks as though I am winning in my battle to have the Mobiliser recognised by the military as a therapeutic tool, an adjunct to physiotherapy.  They have just bought a batch for use in some of their intensive rehabilitation centres and with any luck, all military medical rehabilitation departments will soon be able to order Mobilisers.

My job today was to demonstrate the use of the Mobiliser to the staff who will be responsible for introducing it to their practices, along with David Newbound.  I also explained my theories as to how it acts on spinal mechanics and helps to restore normal motion.

Essentially, the spine is able to perform large global movements such as bending and stretching, leaning forwards, backwards and sideways.  But it does this with the help of a lot of very small accessory movements between the vertebrae, which slide and tilt and twist on each other infinitesimally in order to produce the obvious, big movements.  Stiffness occurs when the accessory movements - the slide and the tilt and the twist - are reduced, by disc dehydration, joint disruption such as injury or by muscle spasm.

I believe that the Mobiliser - with its regular, fairly gentle but relentless repeated movements - calms  muscle spasm and then (using the gravity-induced backward shear I discussed in the last post) passively pulls the joints apart to restore the sliding accessory movement.  Over time, with the muscle spasm reduced and joint mobility restored, pain is reduced and function improved.

What the Mobiliser doesn't do - and this is why, particularly when there are rotational components to a spinal problem, you still need a therapist to mobilise the spine with hands or feet - is to restore the twisting accessory movements.  After all, it's a machine, and not capable of intelligent touch or clinical reasoning.  But it is a very useful adjunct to manual therapy and exercise therapy, and I believe is a valuable tool in the treatment of chronic spinal stiffness.

If you're interested in discussing using or hiring a Mobiliser, the best option would be to contact Back in Action, or pop into one of their shops to try it for yourself.

And if you'd like to read my original research, please e-mail me for a copy.

Why use the back block?

Posted by Nell Mead at 10:30 on 18 Apr 2011

I had an e-mail this week from a blog reader who asked whether the Sarah Key exercises I've blogged so far would be good for spondylolisthesis.

Spondylolisthesis is a condition which affects 3-6% of the population in which one vertebra - most commonly the L4 or L5, at the bottom of the spine - slips forward on the one below it.  Left uncontrolled, it produces a more exaggerated curve of the low back, like those you often see in men with really big tummies or pregnant women.  The grade of spondylolisthesis is determined by an X-ray to see how far the upper vertebra has slipped - a grade I being a forward slippage of 1/4 of a vertebral body, grade II being half, and so on.  Surgeons tend to get involved with grade II+ spondylolistheses as the slippage is more likely to be a danger to the spinal cord.

There is a fair amount of evidence in the literature for strengthening the core muscles of spondylolisthesis patients, particularly the transversus abdominis which acts like an internal corset, and the multifidus which acts like the guy ropes of a tent to shore up and stabilise the slipped vertebra.  I'll go through some useful exercises for these in future posts as they are excellent for any form of instability, but incidentally this is one situation where I think exercise methods such as Pilates can be really useful.

As well as core exercises, I really rate the back block for spondylolisthesis patients.  Traditional physiotherapy extension exercises are carried out from the prone (face down) position, where the patient pushes up onto elbows or hands to extend the spine.  I don't use this for spondylolisthesis patients because gravity, as you can see from the top diagram, acts on the vertebrae to produce an anterior (forward) shear - exactly the same force that causes spondylolisthesis!  Lots of physiotherapists have therefore moved away from prescribing extension exercises to spondylolisthesis patients.

By contrast, however, the back block exercises are done in a supine (face up) position.  This results in gravity pulling the vertebrae towards a position of backward shear, as you can see in the lower diagram - and thus into a more neutral position away from the spondylolisthesis slip.

The effect of this tends to be (gradual, cumulative) better alignment of the spondylolisthetic segment, and also reduced muscle spasm and reduced pain.

Of course, not every case is that simple: longstanding spondylolisthesis problems often lead to altered muscle control and movement patterns, as you start to compensate for the discomfort of the injury.  Using a back block doesn't replace a proper assessment and treatment plan in every case. But if your physio isn't already getting you onto a back block, it might be something to discuss.

Please feel free to ask questions - either here on the blog or by e-mail - or get in touch to arrange an appointment.

Sarah Key Method - Back Block

Posted by Nell Mead at 14:00 on 9 Mar 2011

Time to get back to backs!

This exercise is another of Sarah Key's, and is great for stretching your low back.  You'll need what Sarah calls a back block; they're also known as yoga bricks.  Roughly the size of a house brick, they come in a variety of materials including wood, bamboo, cork and foam - I usually use one made of solid foam, though in an emergency I have also been known to use a hardback copy of a Harry Potter book!

When we spend all day with our spines in an upright position (sitting, standing, walking, running), gravity combined with our bodyweight squashes our spinal discs, and over the course of the day they flatten out a bit.  It's not unusual to be 2cm shorter at the end of the day than you were at the start.  Generally, the discs rehydrate and plump up again overnight when you're lying flat, but over time - with age, or particularly with injury - the flattening starts to have a greater effect than the rehydration, and you develop stiff spinal segments.

Sarah's theory is that this process is reversible if you regularly take steps to decompress your spine, and this is where the back block - coupled with the appeasing exercise I described before - comes in.

• Lie on your back on a firm surface such as the floor, knees bent so that your feet are on the floor, and feet and knees together.
• Squeeze your knees and buttocks together. Keeping them squeezed, roll up your spine, curling your bottom off the ground first, and - bone by bone - then your low back, mid back and upper back, until your weight is on your feet and shoulders.
• Bone by bone, roll your way back down again, trying to make the space between each bone as long as possible, and making sure that when you reach your pelvis, the left and right sides hit the ground at the same time.
• Make sure your knees and buttocks are squeezed together, and roll all the way up to your shoulders again, bone by bone.
• This time when you are at the top, slide your back block underneath your pelvis (NOT under your low back) and roll your bottom down onto it.  The block should be horizontally aligned and on its shallowest side.
• Slide (don't lift) one foot along the ground and away from you, and then the other.  Allow your ankles to relax and roll outwards.  Relax your calves, then your knees, then your thighs, buttocks, low back...
• Let your arms roll outwards so that your palms face the ceiling, and relax completely for a minute.
• Then slide one foot back up towards you, and then the other.
• Squeeze your knees and buttocks together, and roll your way up off the block (at first this may be sore; don't worry, this is quite normal and it does get better!)
• Slide the block out from underneath your bottom, and roll down just as you did before.
• Now do 30 seconds of the appeasing exercise, and repeat the whole thing three times.

NB - any discomfort you feel on curling up off the block should fade quickly and should improve over the first few days of practising this exercise.  If it is too painful, or remains significant for more than a week of doing this, you should discontinue the exercise and get your back assessed.  (Of course, I'd recommend that you see a Sarah Key-trained physiotherapist...)

Thanks to the lovely Graeme Marsh for posing for these pictures at The Foundry.