Once the stage is set with adequate rest and any necessary drug therapy, the following exercises reverse the structural and physiological changes of the motion segment. Basic theoretical treatment regimens, using various combinations of the exercises for specific back disorders, are in Chapters 2 to 6.
This is the ultimate 'appeasing' exercise. It is the least taxing and therefore least frightening exercise in the early loosening of a jammed segment. It is performed in the horizontal supine position to eliminate compression of the spine.
The primary function of the knees-rocking exercise is to fan open the posterior compartments of the spine like flaring out a deck of cards. The action stretches the muscles down the back of your spine when their tonic hold has pulled the interspaces shut. Releasing the muscles un-jams the facets and releases the pincer effect on the intervertebral disc. Thus the passive stretching inhibits the additional closing down effect across the inflamed vertebral segment. By providing 'active' decompression it produces the first glimmer of the spine lifting off the compressed segments. It is a very efficient first-base exercise.
Like spinal rolling which you will read about below, rocking the knees to the chest is very effective if you have just jarred your spine or hurt it in some way. Rocking has an immediate neuro-physiological 'switching off' effect which defuses the alarm and preempts the local muscles locking up the spine. The to-and-fro rocking action familiarises your back with movement again so it doesn't have time to get stiff. It keeps your back moving in a non-threatening way and encourages the fundamental physiologies— active disc metabolism, unhindered blood flow and proper drain-age—to resume. Disc nutrition is enhanced by incremental amounts of fluid being pumped through, while the pressure changes stimulate the synthesis of proteoglycans which thereafter provides a more active osmotic pump.
In the acute phase the pull-and-release evacuates the inflammatory products from the site of injury. With more chronic conditions, the main benefit is the physical stretching of the tight structures. The non-weight-bearing loosening of all the soft tissues of the posterior compartment, including the back wall of the disc, immediately gives the tight segment more freedom to move. The much vaunted breakthrough of injecting one's own healthy disc cells (auto-logous) into degenerated discs is doomed to failure if the target disc is not made to 'suck and blow' after the procedure has been done. If it remains static it is impossible to keep the new cells alive.
Although rocking the knees to the chest is most effective for segmental stiffness of L5 and L4, it is also effective higher up in the lumbar spine where there may be some rotation of the segment as well. It is particularly effective at breaking up what seems like armour-plated stiffness across the back of your pelvis that often accompanies an acutely sore back. You can move your legs carefully by manoeuvring your thighs as levers to drive around the back of the pelvis, feeling for hard patches—and this is where you tarry. You can minutely oscillate the thighs up and down, left to right from dimple to dimple, or you can trace a circular outline around the apices of your triangular-shaped sacrum, first one way then the other. As you get more adept, you will feel that the hard patches coincide with the painful spots and this is where you stay, rocking gently on them until they 'melt' and the going gets easier.
Simple as it sounds, rocking the knees is often difficult to get started, let alone do well. If your back is in acute distress it is not easy to get the knees to the chest. Your legs feel heavy and your spine is loath to bend, and you may get stabs of pain as you grapple with lifting your thighs. As the spine starts to round more easily, your hip joints often complain about being bunched onto the chest. It may be more comfortable for the hips if you allow your knees to part widely around the abdomen. (You may also find that one leg is more comfortable doing this movement than the other.)
With the more chronic disorders, where your lower back may have been stiff for decades, the cement-like rigidity is often unwilling to yield. The lower segments move as a rigid block, with all the hinging taking place at the hips and the upper lumbar levels. As the segments ease apart, your back starts to round more easily, making it a natural progression to spinal rolling, which is discussed below.
The emphasis with rocking the knees is to keep the movement as subtle as possible with the arc of movement only a few centimetres. Don't be tempted to tug at your knees with the muscles in your neck standing up. Don't jab your head up to meet the knees. Leave your head and shoulders calm and relaxed on the floor and gently oscillate your legs with the fingers interlaced around both knees. As your back relaxes, a sense of movement will dawn, like a piece of frozen meat thawing. The tightness will fade as you feel the vertebrae gapping open at the back. Don't hurry and try to imagine the vertebrae segments pulling apart.
The correct way of rocking the knees to the chest
• Lie on your back on the bed or on a soft surface on the floor.
• Brace your low back by sucking your navel in hard. If your tummy is weak, push in with one hand on the front of the tummy for reinforcement.
• With the other hand behind your thigh, pull one leg up to the chest. As soon as one foot is off the bed you can use both hands to pull the leg onto the chest.
• Bracing your tummy in the same way, pull the other leg onto your chest. Crossing your ankles makes the legs less unwieldy.
• Cup a hand over each knee and then move your legs so the thighs rest at 90°. Oscillate gently in this position, with the movement almost imperceptible.
• For high lumbar problems, take your knees closer in to your chest.
If your hips are tight you can cross your ankles and link your wrists across your upper shins and oscillate in this position.
Spinal rolling seems so easy yet it is very sophisticated in a neuro-physiological sense. The alternate tipping back and forth along the spine helps break up the domination of the over-active erector spinae muscles and the corresponding reflex inhibition of your tummy muscles. As you tip towards your toes you use the abdominal muscles and as you go back the other way you use your back muscles. By 'selectively recruiting' both groups you interrupt the status quo when your back is bad: when your back muscles will not switch off and your abdominal muscles cannot switch on.
Spinal rolling is very important in self-treatment. It breaks up the superficial brittleness of the column and is the simplest form of spinal mobilisation. Each vertebra has its turn at gliding past its neighbours as your bodyweight rolls over it. Again using the analogy of the keyboard, rolling along the spine is like rolling your forearm and wrist down over an expanse of piano keys as they depress one after the other. Each vertebra has its own musical note ofstiffness, although the jammed one is especially shrill as you press over it.
In this regard, rolling along the spine is a primitive diagnostic tool. By rolling over the segments you can isolate your problem level. You can 'examine' the L4-L5 and the lumbo-sacral interspaces by clasping your hands behind your knees and nearly straightening your legs with toes high in the air. The weight of the legs and the long leverage make it easy for you to tip back and forth over the lower end of the spine to see whether you elicit pain. To isolate the midlumbar level, hug your knees a little closer to the chest so that they make a shorter lever. Depending on the bulk of the upper chest, the angle at the knees will be closer to a right angle. To isolate the thoraco-lumbar level, you have to shorten the lever even more by having your legs pointing almost straight up to the ceiling. To tip your weight towards the higher end of the lumbar spine, you simply bend and straighten your knees in the air, which rocks the body back and forth.
All these movements require a fair degree of control and will not be possible in phases of acute pain. Simple as they sound, it is often too painful to get your spine rounded sufficiently and you struggle about stranded, like a beetle on its back.
Or it may not be painful at all, simply stiff. The patch of immobility may be loath to press out the other way because the vertebrae cannot glide backwards. (I can see this as a small hollow scoop in the low back when you bend forward from the standing position.) It makes rolling along the spine like bumping over a square wheel, with a clonk as the flat patch hits the floor. It requires extra pulling in below the belly button to shrink in the lower abdomen, to force the stiff patch out the other way.
As a therapeutic exercise, spinal rolling is the all-round panacea. It is effective first thing in the day if there is early morning stiffness. It dissolves guarding muscle spasm which can hold your back as rigid as a plank. It is also useful if the spine has just been jarred; in this case, the rolling should be as relaxing as possible, along the whole length of your spine. As everything loosens up, your legs tip right back over your head and as the spine softens it is easier to isolate the problem level.
Loosening the specific vertebra requires small range pivoting, back and forth with small amplitude excursions, right on the painful spot. You have to grab your knees and steer yourself back and forth with precision. Working the vertebra free is like pressing out the stiffness, pivoting back and forth on the carpet. You can also pause in mid-flight, staying motionless on the spot to allow the spine time to sink down and relax around it.
Note: Don't be confused by the picture following. Most times, this exercise will be performed as small 'pivoting' spinal rolls, almost on the spot. This prises the specific problem vertebra free and settles local spasm.
• Fold a bath towel double and place it on a carpeted area of floor to roll on. Do not attempt to roll in bed.
• Lower yourself down carefully to lie on your back on the floor.
• Gather up both thighs and link your fingers under them, or around your knees, whichever is easier.
• Lift up your head and neck so your low back makes a wide rounded 'U' shape on the floor. (To help keep your upper trunk forward you may need to bend both elbows out to the side as you hold your legs.) The stiffer you are the more difficult it will be to get into this position.
• Once in position, rock gently back and forth along the spine with small amplitude movements.
• Attempt to pivot on the stiff link in your spine which will be obvious by its 'bruised-bone' tenderness as you roll over it.
• Use your legs for leverage. As you straighten them out they alter your weight distribution and make it easier to tip towards the lower end of the spine. If you keep your legs bunched up on your chest it will focus the rolling towards the upper end of the spine and require more jerking effort of your head to bring it down to the lower end.
• Continue for 15-30 seconds, trying to relax as much as possible as you do it. Let the gentle rocking motion mesmerise you.
• To rest, put one foot on the floor, and then the other, holding on with your tummy as you lower each leg. Leave both knees crooked, feet flat on the floor.
• Resume at one-minute intervals and repeat up to three times.
• This is not an easy exercise to overdo. Cramp of the tummy muscles and the muscles at the front of your neck may be the only things that stop you.
This exercise is an effective way of tricking the tummy muscles to switch on when they reflexly inhibit through the presence of back pain. It encourages the back to let go and the hips to swing freely with walking, which they do not do when your back is painful. It also encourages the abdominal muscles to hold the pillar of lumbar segments secure as the legs move and this protects the low back from ongoing micro-trauma during everyday life. It is a very important first exercise for getting the tummy muscles working. As you do it, make a mental note of the degree to which your tummy muscles are working to hold the midriff stable and attempt to replicate this when you are up and walking about. This is how your tummy should work when walking to help off-load the spine!
The correct way to do legs passing
• Lie on your back on a soft carpeted floor with your head in your arms.
• Tighten your tummy and press your low back into the floor to remove any lumbar arching.
• Bring your left knee towards your left armpit with the knee fully bent.
• As the left leg starts its return to the floor, lift the right leg so the legs pass in mid air, at all times keeping the low back pressed into the floor.
• This is not a 'bicycling action' so you do not straighten either knee at any stage as this strains your low back.
• As each leg comes down, just brush the floor with the sole of your foot between excursions—that is, do not fully rest your leg on the floor.
• You will feel the midriff fully switched on as you control the weighty legs alternately passing one another.
• Continue for 60 seconds, moving the legs slowly and with control.
Reverse curl ups strengthen the abdominal (tummy) muscles and are preferable to old-fashioned 'sit ups' because they do not involve sitting on the pelvis. They also reduce the likelihood of shearing strain across the lumbar segments, as well as exerting less pressure on the inflamed lumbar segment. Although sit ups, spinal crunches and a great variety of abdominal exercises are popular with gymnasiums, they over-work the upper abdominals and tend to lead to spinal compression. On the other hand, reverse curl ups specifically recruit the lower abdominals and in most respects are a less problematical way of strengthening the tummy. Reverse curl ups are relatively strenuous compared to normal sit ups and they have the advantage of demanding greater participation of transversus abdominus. High lumbar problems (from L3 and above) also do better with tummy strengthening done as reverse curl ups.
They should always be done lying on the back, using the abdominal muscles to pull the knees back and forth towards the chin from a starting position of 90°, lifting the bottom as high as possible off the floor. The emphasis should be on drawing in the tummy and bringing knees to the chin rather than chin to the knees. Never lower the legs beyond 90°, nor start the movement by lifting the feet from the floor, and returning them there; the weight of the legs can strain the back.
Try not to jerk the legs up and then let them go. Make sure that both excursions take the same time as you lower your legs under control. If you are weak, the best way to incorporate transversus abdominus is on the return journey. Keep your back round, and press the whole lumbar area into the floor, lowering one cog at a time. Drawing up the pelvic floor also helps. If your back clicks or hurts as you do the movement, pull your tummy in harder and reinforce it with one hand pressed in, rounding your lower back more.
Tummy muscles play an important role in off-loading the base of the spine. They do this by co-contracting with the back muscles which tenses the abdominal cylinder and raises the abdominal pressure. This lifts the spine skywards and increases the tension between the vertebral links. Strong tummy muscles also control the way the vertebrae move during upright activity. They help the vertebrae to tip forward rather than shear when the spine bends. Thus tummy strength plays a critical role in optimal spinal performance.
For this reason, reverse curl ups are probably the single most important exercise in the prevention and management of spinal problems. In short, they not only prevent the spine harming itself but, once a spine is in trouble, they help get the segments back to full function.
When a low back is painful, abdominal strengthening plays an important neuro-physiological role in reducing the hold of the back muscles. When worked strongly they automatically make the long back muscles switch off. This simple-is-genius truism of physiology is a very effective way of making a stiff back relax. Reverse curl ups open up the spinal segments at the back while the tummy shrinks in at the front. The elongation of your spine stretches and softens their muscular clench and allows the spinal segments to ease apart.
The correct way to do reverse curl ups
• Lie on your back on the floor and take first one knee to your chest, then the other.
• Crossing the feet at the ankles and letting the knees fall apart comfortably, take the thighs to 90°, and interlace your fingers behind your neck.
• By lifting your bottom clear of the floor use your tummy to bring your knees up under your chin.
• As you relax and your legs come down, make sure they do not pass beyond 90° which would cause your back to arch.
• When you get into your stride, you can swing your knees up with some gusto, as long as you do not jar your back.
• Repeat fifteen times.
The BackBlock is a simple tool for alleviating lumbar compression and stimulating disc metabolism. You could say the BackBlock's main role is to accentuate anti-sitting postures since it is sitting that most compresses the spine's basal segments. Using the BackBlock emphasises this non-functional 'other' extreme and foils the sustained compression of sitting. It also invokes the negative forces required to stimulate vigour of the discs' metabolic processes.
At all times, when using the BackBlock, it is important to bear in mind that discs do not have a blood supply and their nutrition is tenuous, even at the best of times. Discs degenerate much earlier in life than other tissues, and even when healthy may be unable to survive mechanical duress under adverse nutritional conditions. Discs critically need the additional 'imbibition pump' which physically sucks in water to augment the steady 'osmotic pump' of proteoglycans dragging fluid in. These two engines—diffusion (osmosis) and convection (pumping)—must work hand in glove to conduct nutritional traffic through the discs.
Apart from exchanging nutritional fluids, the pressure changes induced by the passive extension of the BackBlock help discs carry out essential maintenance and repair. The disc cells most active in manufacturing proteoglycans are directly stimulated by variations in disc hydration; thus a vigorous tidal exchange actually stimulates regeneration of the very cells that help attract water in the first place. The opposite is also true as discs degenerate: the more meagre the fluid exchange, the more sluggish the multiplication of proteo-glycans, the magical x-factor of discs that attracts and holds water. The discs slowly starve as their increasing immobility locks out movement and the regenerative cycle slows down.
In addition to the pressure-induced physiological processes, the direct physical stretching of stiffened disc walls makes them more compliant and accommodating to imbibed water. As more fluid is retained in the nucleus, this part of the disc can shoulder load again, thus alleviating compression of the sensitive outer disc wall.
In this way the typical pain of a 'stiff spinal segment' is lessened. With better clearance between adjacent vertebrae as disc height is restored, there is more room to move between the bony parts of the spine and the typical pain of 'facet joint arthropathy' is also alleviated. In cases of 'segmental instability' where reduced hydrostatic pressure makes the disc a weaker spinal connector, augmenting the water volume of the drier disc can make the segment more secure.
Apart from pulling the segments apart the BackBlock reestablishes the spine's proper 'S' bends. If the back is too stooped it straightens it. In the thoracic area it opens out a round-shouldered look, and at the keystone of the spine—the base—it pushes the bottom in and straightens the entire skeleton. On the other hand, if the low back is too hollow, it can reverse that too. Lying passively over the BackBlock, the vertebrae inch backwards and the high arch of the lumbar area slowly drops flatter towards the floor.
The BackBlock is the natural antidote to our 'C' shape of habitual slumped sitting. Placed under the sacrum and the thorax in turn, it prises out the hours of compression and stretches the soft tissue contracture of the front of your spine and hips (which have also spent too much time bent). Thus the BackBlock uses gravity to press your skeleton out straighter, aligning it more trimly over its narrow base. In this way it deals with its two main pain-making causes at once: basal compression and the spine's dynamic imbalance over the sacrum.
Although our nearest cousins the apes have a rounded 'C'-shaped stature, with their heads carried well forward, in front of the line of gravity, they can reverse any problems this might cause by swinging through the trees on their arms (brachiating). Human beings have no such means of everyday traction to straighten their spines, and must counter the ill-effects all their lives. Most of us have to work at keeping a good posture and decompressing our spinal bases otherwise we are all in line to develop low-back pain. A BackBlock—nothing more than a simple chunk of wood (or plastic which is lighter for travelling)—is a most effective tool.
You must always start off using the BackBlock on its flattest side. As your legs drop down and you feel the pelvis pulling off the spine's base you often feel a tug in your back, right where it hurts. It feels as if it really means business; as if a screwdriver is drilling right into your pain. At first, it may take some concentration to relax and let the discomfort fade. Some people cannot even lie on their back on the floor, while others must make do with a lesser form using a flattish book or folded towel under their sacrum. It may take several weeks to progress to using the BackBlock. Usually, you progress from the flattest side to the middle height within a couple of weeks, while others go straight to it if they feel nothing is happening. You should not attempt to use the BackBlock on end first off.
Only remain on the BackBlock for one minute (60 seconds), before following with the mandatory steps 2 and 3. Remember, greatest fluid shift through the discs happens at the point of loading and unloading, and that it is pressure changes you want. So it is better to do repeated short sessions rather than one long one. Also, if you stay there too long it can be difficult to get off. Even so, there is always a murmur of discomfort as you go to lift your bottom off the Block.
If you do stay on the BackBlock too long, what should be a little pain becomes a big pain as you go to lift off. Although this does no harm, it can be unnerving and you will think the BackBlock does not agree with you. Better to do shorter sessions, followed by the usual rocking the knees to the chest and reverse curls after the BackBlock has been removed.
It is imperative to always follow the BackBlock with the low abdominal exercise of reverse curl ups. After rocking the knees has first removed the castness of your back, and accommodated it to humping round the other way, you should go straight to them. If you fail to do the prescribed number (or worse still none at all) your back will feel very stiff and sore over the next few days. Reverse curl ups and the BackBlock should always be balanced, otherwise the benefit is reduced. If people are sore after using the Block, they have invariably forgotten their tummy exercises.
The BackBlock under your upper back usually creates a greater feeling of well-being, there and then. Apart from taking the hunch out of your spine it makes you feel taller and looser in your own skin, especially when you take your arms over your head, inter-linking fingers and turning the palms away. You can feel your whole spine pulling out of your pelvis like a cobra out of its basket with a beautiful emancipating stretch which goes right from your chest through to your waist and low back.
The BackBlock should be placed on its flattest side, lengthways under the long curve of the thoracic spine, so the top edge is level with the top of your shoulders and the lower edge at high waist level (sometimes, if you are short, it digs in here until you loosen up over the next couple of days). As you lie back, you may need to lower your head back to the floor with your hands and when there, elongate the back of your neck by pulling your chin in. Some people feel nauseated on first putting their head back, but this passes as they get used to it.
To help reverse the pinched-forward look of the shoulders which so often goes with a stooped upper back, you can stretch the pectoral muscles at the front of your chest by taking your arms down to your sides in wide semicircular movements (the 'angels' wings') as you lie over the BackBlock. Chest expansion and breathing control is also enhanced if you do these sweeping movements in time with your respiration. Inhale as the arms go up to above your head, keeping the back of the hands in contact with the carpet all the way around. Take a breath or two at the top and then exhale for the return journey, as your arms come down to your sides again. Both ways, the arms will lift off the floor when they approach the 'eagle stretch' position in the top quadrant of the semicircle. Through both excursions up and down, there will usually be a stretch across the front of the chest and into the upper arms.
To get off the BackBlock when it has been under the thoracic spine you simply roll off to the side like a log. Do not attempt to sit forward because this can strain your neck.
Although it gets progressively less painful as you repeat each one-minute session on the Block, the structural changes take some time to reverse and definitive signs of improvement may be quite slow to be realised. Remember that discs have a very low metabolic rate and that they are slow to regenerate, just as they were slow to degenerate. Over the first week or so the pain feels less heavy and dull and your back works better. A good sign is when the back feels 'lighter', as if you are no longer dragging an armour-plated shell around with you. It feels less dense with movement, as if the segments are freer to move individually, and your hips swing when you walk. Especially in a prematurely 'old' and chronically stiff back, these changes and the easing of pain can feel nothing short of miraculous. With more acute problems however, it is less straightforward. Where there is guarding from the muscle spasm, the BackBlock gives better results if it is taken more slowly, and if you have had a bad flare-up you should stop using it for several days (anything from three days to two weeks) until any newly acquired 'fragility' has dispersed.
Incidentally, you can get the same effect by using a telephone book, or something flatter if you need to. A proper BackBlock is better than a miscellany of books because it can be more easily progressed through its various stages: from its lowest side, when the spine is particularly impacted, to the highest side when the spine is in its final stages of rehabilitation. Apart from its stringent dimensions, it also serves as a neat and timely reminder as you spy it sitting in the corner by the TV. Just having it there makes you more likely to use it. And the BackBlock really comes into its own with travelling. All the carrying of heavy luggage, plus the long hours spent sitting and sleeping on unfamiliar beds means that you often need it most when you are away from home.
The correct way to use the BackBlock
• Lie on your back on the floor with knees bent.
• Lift your bottom and slide the BackBlock sideways on its flattest side under the sacrum, the broad flat bone at the base of the spine between the two dimples of either buttock.
• Slowly straighten one leg, then the other, by sliding the heel out away from you across the carpet.
• With both legs straight, relax completely and let the weight of your legs pull the spine out. Attempt to keep your heels close together although the feet can roll out. There is frequently a local discomfort at the base of the spine and higher up if another level is jammed there. You should be able to sense the spine pulling apart longitudinally. It is usually an 'agreeable' discomfort, but it should feel as if it means business. Do not be alarmed by the pain. Go with it.
• If you feel absolutely nothing with the BackBlock on its flattest side, then immediately progress to its middle side with the thin edge transversely across the sacrum. You can experiment with sliding the BackBlock up and down under the sacrum fractionally to feel where it is more comfortable. Where it feels best is where it should be. It must never be under the spine itself, where it will be very uncomfortable. (I am often surprised how patients forget and put it there.)
• With the BackBlock at the right height, remain in position for one minute, completely relaxed as the legs imperceptibly drop down.
• After a minute, slowly bend one knee and slide the foot up towards the buttock, then the other.
• Lift your bottom off the BackBlock. This can be painful but is no cause for alarm. Move slowly and keep the tummy braced as you slide the Block out to one side.
• Lower your bottom to the floor and then do the rocking knees to the chest exercise. Take knees to your chest one by one, then interlace your fingers around both knees (or cup one hand over each knee— whichever is the most comfortable) leaving your head on the floor. Do not tug at your knees with the muscles in your neck standing up with exertion. Rather, oscillate them gently back and forth, persuasively bringing the spine around the other way into a hump.
Initially this may be uncomfortable, with a sense of tightness across the base, but as you continue you will feel the back rounding and lower interspaces starting to gap open. Persevere until the discomfort across the lower back has eased. This may be immediate or can take several minutes of gentle rocking. When your low back feels more supple, it is time for strengthening the lower abdominal muscles. This is done with the reverse curl ups.
• Do the reverse curl ups in strict accordance with the instructions already given, fifteen in number.
• Repeat the one minute on the BackBlock, the rocking and reverse curls another two times, so that by the end you have done 45. This routine is best carried out at the end of the day when the spine is most compressed. Three to four repetitions of the three steps takes between 10 and 15 minutes. A good place to do it is on the floor in front of the television.
• Although the ideal time to use the BackBlock is in the evening, some people have a better day if they do it first thing in the morning. Some of my patients keep another BackBlock at work to use in the lunch hour after sitting scrunched at their desks all morning.
• It is sometimes kinder to do the first round with the BackBlock on the flattest side and then progress to its middle height for the second and third round. It takes several months before most impacted spines are ready to progress to using the BackBlock on end.
• Intensive use of the BackBlock must be entered into slowly. At all times, the period over the BackBlock must be matched with equal time doing reverse curl ups. If you use the Block without these afterwards your back will be cast and stiff after getting up, and everything will be much more sore and achey.
This exercise is very effective for restoring segmental control when the small intrinsic muscles (mainly multifidus) have atrophied due to the spine moving as a block. Apart from being the first spinal strengthening exercise, it also restores spinal pliability by helping the segments move individually. It literally breaks the hold of muscle spasm and allows the segments to jostle freely beside one another and pull apart. Segmental movement and control is essential for returning spinal health. As the segments draw away and compress like a concertina, they suck and squirt fluid which nourishes the discs. At the same time, the induced pressure changes stimulate disc metabolism. Your low back often feels tight and sore after a few repetitions of this exercise, so you should always follow it with the knees-rocking exercise and a number of reverse curl ups.
The correct way to do segmental pelvic bridging
• Lie on your back with your knees bent and your feet as close as possible to your bottom and your arms beside you.
• Clench your buttocks and pull your tummy in tight as you tip your pelvis back, making your low back into a round wheel.
• Pressing your low back into the floor, roll up your spine, one cog at a time. Try to feel each segment in turn meeting the floor, particularly the recessed ones which won't press easily into the carpet. Take care not to push your arms into the floor to help you.
• Continue rolling right up your spine to the base of your neck one cog at a time, until your body forms a straight line between shoulders, hips and knees. Rest comfortably, taking weight on the prominent bump at the base of your neck, chin pulled in. For added stretch, you can take your arms over your head, interlacing your fingers and turning the palms away.
• Remain in this position for 15 seconds. It is important to keep your gluteal muscles switched on by pinningyour knees together.
• Initiate the return journey to the floor by making a horizontal crease across your belly at navel level by sucking your tummy in hard.
• Fold your back down to the floor, one cog at a time, distinctly feeling your spine pass over each spinal segment. It is always difficult to press the back at waist level into the floor.
The Ma Roller
The Ma Roller is an effective way of mobilising the chain of facets running down either side of the spine. It looks like a convoluted rolling pin with two large rounded humps either side of a central depression. You position the Roller under the spine, with the row of knobs you can see through the skin over the central gully, and you mobilise the joints either side by rolling up and down as the Roller moves on the floor.
The Ma Roller is more effective under the thoracic spine where the facet joints are nearer the surface (although it hurts more resting your full weight down) but it is still a useful way of isolating and mobilising stiff lumbar facets. As you oscillate back and forth on the painful spot(s), like a bull rubbing against a low branch of a tree, you feel the bitter sweet pain of the stiff joints being worked.
To specifically target the lumbo-sacral facets you position the Roller just above the two dimples in your low back (you are in the right spot when it hurts more) and hump and hollow your low back in a pelvic rocking action over the Roller. As your back hollows it bends around the prominence of the Roller, letting your bottom reach the floor. As your back muscles relax you can feel the delicious pain of the joints being pushed to their limit of range.
You can get better access to a single joint by removing the Roller and re-positioning one end only under the side of your spine. With the other side of your back lying on the floor you get deeper pressure onto the problem joint, although you must take care not to cause bruising as you seek it out.
In mobilising an acutely tender facet, it is better to use a tennis ball instead of a Roller. The softer, more yielding ball is kinder to the joint and minimises the risk of bruising. A tennis ball is also much easier to carry with you when travelling.
The correct way to use a Ma Roller
• Lie on your back on carpet with your knees bent and feet flat on the floor.
• Lift your bottom and place the Roller under the midline of your back with the knobs of your spine situated over the central gully of the Roller.
• Raising your upper body with your elbows, gently roll your lower spine up and down over the Roller as it makes small oscillations on the floor.
• The problem joints cause a shriller pain as you pass over them. Stay on these points, 'worrying' them as you travel back and forth.
• To avoid bruising, never spend more than 60 seconds working one joint.
• To remove the Roller, lift your bottom up carefully, taking the Roller out to one side.
• Relax the back by lying down gently on the floor and rocking the knees to your chest for 30 seconds.
Squatting is the natural predecessor to sitting. In an earlier evolutionary state, although we might have run all day holding a spear, at least we squatted around the campfire in the evenings and eased out the spine's basal compression caused by the day's activity.
Squatting pulls the spinal segments apart and vertically opens the intervertebral spaces from both above and below, rather like extending a tubular fishing net by holding a string at the base with your foot and pulling up the top rim. As the spine elongates, the discs drag apart and suck in fluid.
Squatting comes into its own as the antidote to sitting when circumstances are not right for using the BackBlock. It pulls the segments apart after they have been compressed by the thoracic spine bearing down during lengthy periods perched on the sitting bones. Squatting is the natural partner to the BackBlock. Squatting levers open the back of the disc space more while the BackBlock levers open the front, with the result that the entire circumference of the latticed walls is pulled up.
Deep in the squat your knees often complain, but after a week or so they get to love it and you can stay down longer. Keeping your knees wide while squatting and trying to get as much bend as possible at the hips also helps to release tight gluteal muscles which go with low-grade back problems. The more you can force yourself into the extremes of the stretch, the more you break up the overall picture of tightness and the more easily your spine will bend afterwards.
All of us should squat at regular intervals throughout the day, especially after impact activities like running, walking or playing sport. Sometimes you do it instinctively after standing for a long time, when the spine feels a need to break free of the painful castness of spinal compression.
• Stand with your heels and toes close together and, holding the side of the bath or a secure rail, bend the knees and drop your bottom to the floor. (You can do it freestanding, as you can see in the picture, but holding on and leaning back gives you a better stretch.)
• Take your heels to the floor and part your knees widely as you take your bottom as close as possible to the floor.
• Bend your elbows to pull yourself forward and drop your head as low as possible between your legs, attempting to turn the full length of the spine into a long, rounded hump.
• In this position gently bounce your bottom to the floor while keeping your head tucked down. Continue for 30 seconds.
• While in this position, suck your tummy in a notch or two and sense the increased separation of the lower segments as the pelvis drops down off the base of the spine.
• To stand up, pull your tummy in and push strongly through the thighs.
If you do not have a suitable object to hang back from as you squat, you will not be able to get your heels to the floor. But you will still be able to sense your spine 'growing' as you pull your tummy in, particularly if you rest your forearms on your thighs to alleviate the weight of your torso. As your back rounds, you can feel your bottom dropping down closer to the floor.
This exercise mimics the longitudinal stretch of squatting and also improves the muscular control of the spine. It stretches shrunken facet capsules and back walls of discs (and the other transvertebral structures). Toe touches improve the coordination and strength of all the muscles which control bending.
Although for years people have been told never to bend if they have a bad back, the benefits of doing so are vast. The deep bend pulls the spine out of its vertical clench and releases the discs to imbibe fluid. It also re-educates the power of the intrinsic muscles which specifically control the tipping of the segments.
Toe touches also reduce the over-activity of para-spinal muscles, a common feature of chronically painful backs. They pass control back to the deeper muscles (the spinal intrinsics and transversus abdominus) so the vertebrae are less likely to shear as the spine bends over.
Toe touches have another important role in the later stages of treatment. Done repetitively and with gusto they plump up the lumbar discs. As the spine rhythmically bends and straightens it enhances fluid exchange through the discs, while subjecting them to the pressure changes which stimulate discal regeneration.
The correct way to do toe touches
• Stand with the feet 15 cm (6 inches) apart and parallel.
• Contract your buttocks and pull your tummy in to shrink the circumference of the lower abdomen, while at the same time drawing up your pelvic floor.
• By tipping your pelvis back slightly so your lower back humps, take your chin onto your chest and curl forward, from the top down, towards the floor.
• Make sure the lower abdomen feels firm and secure, like a tense tube bending with control in the middle.
• Slide both hands down the front of your thighs and on towards the floor.
• If your hamstrings are tight you can bend your knees so you hang there like a gorilla.
• In this position keep the lower abdomen pulled in like a greyhound. Although your tummy will feel pulled in and hard, your lower back should feel a gentle stretching discomfort with a sense of letting go.
• Let your head dangle and your arms flop.
• Try and visualise the bottom vertebrae gapping apart as the bottom of your spine rounds into a hump.
• Without losing the bracing control of the tummy, bounce imperceptibly at the bottom of the bend. The bouncing should be gentle and coaxing, not vigorous. Do several small bounces and then tighten your buttocks in preparation for coming up.
• The return to upright stance has to be done in a controlled way, with the abdomen fully sucked in and the buttocks clenched.
• Come up with an unfurling action, initiated by the pelvis tipping backwards and the rest of the spine following on, the head coming up last.
• In the way that correct curl ups emphasise segmental control, the same is true of toe touches. Especially on the return journey, each vertebra, one after the other, should tip backwards until the upright posture is arrived at.
• Repeat the toe touches three times, trying to get further down with each imperceptible bounce.
This variation of toe touches comes into its own when treating facet joint problems and chronic disc problems. In the forward bending phase, where you stand with your legs wide apart, taking the left hand down past the right ankle (and vice versa), the capsules of right facet joints are stretched and loosened. You will always find it is harder bringing your hand to the ankle of the same side as your pain. Thus if you have a right-sided facet problem, it will always be more restricted taking your left hand to the right ankle. The inelastic facet capsule on the right finds it difficult to give out and stretch as the tail of the vertebra swings across to the left.
The return journey to upright position, through the diagonal unfurling movement from the floor, is particularly valuable in strengthening the multifidus muscle, usually indicated after a facet locking episode and cases of facet instability. As you come up from taking the left hand past the right ankle, right-sided multifidus pulls on the tail of the vertebra and swings it back towards the midline, thus untwisting the spine. Strengthening this small muscle, which blends so intimately with the facet capsule, helps shore up the joint and makes it less likely to slip out of place. When you have a one-side problem, it is important to repeat the exercise more times to the problem side.
The correct way to do diagonal toe touches
• Stand with your feet 1 metre (3 feet) apart and your hands by your sides.
• Pulling in the tummy hard and clenching the buttocks, bend forward taking the right hand down towards the left ankle.
• If possible, take your hand past the ankle and make small bounces, all the time keeping the tummy pulled in.
• Keeping the hands low, return to the vertical in a diagonal unfurling action, initiated by your buttocks contracting and rolling the pelvis back. Do not take your hands above your head.
• Repeat four times to the problem side to every one to the good side.
This twisting action is done on the floor with the spine unweighted, which puts minimal pressure on the discs as it opens the facet of the upper side. Repeating the stretch in the other direction stretches the disc wall the other way and forcibly closes the facets which had previously been gapped.
The twisting stretch of the spine always makes subsequent longitudinal separation much easier and you will notice this yourself when exercising. The spine feels looser to bend after it has twisted both ways first, and you will always get better separation on the BackBlock doing your twists first.
Floor twists also stretch the nerve root where it has become tethered to the inside of the spinal canal or the intervertebral exit canal. Although root sleeve fibrosis is more common after the inflammation of disc prolapse or facet joint arthropathy, it can also exist with loss of disc height through puckering of the intervertebral tissues and the crowding on the nerve.
To get full stretch on the nerve and its rootlets, you have to get proper straightening of the uppermost knee. The same stretch also increases the tension through the hamstrings muscle of the same side. This is valuable because the hamstrings often retain a low level of contraction when there is chronic inflammation of the low lumbar nerve roots. Apart from being a mild source of pain in itself, the lack of extensibility of the muscle disturbs the sit of the pelvis and shortens the length of stride of that leg during walking. Both factors exert a subtle background influence on the rate of recovery of the spinal problem.
The correct way to do floor twists
• Clear a large uncluttered space on the floor.
• Lie down on your back and bring both knees to the chest, one at a time.
• Place both arms outstretched on the floor at shoulder height with the palms facing the floor.
• Keeping both knees high, let both fall over to the right so the right upper thigh is lying along the floor. As the legs go over, try to prevent the left hand lifting off the floor.
• Make sure that both knees remain as high as possible on the floor with both thighs level, side by side.
• In this position, straighten the top (left) leg at the knee and take hold of the left foot with the right hand. If possible bring the left foot closer to the nose with the right hand.
• Hold for 30 seconds, bouncing the leg minutely by pulling on the toes.
The Cobra is for stretching—not strengthening. This exercise can be potentially troublesome if it is done too early in rehabilitation. It comes into its own later on to finish the job.
The Cobra involves lying prone with the palms face down on the floor underneath your shoulders. With a straightening action of the elbows, your shoulders are lifted up and the spine drops passively into a hanging arch.
The action does three things: it forcibly stretches the anterior (front) disc wall and the soft tissue structures spanning the front of the intervertebral space; it compresses the back of the disc; it also maximally closes down the facets at the back of the spine which has a regenerative effect on the growth of joint cartilage.
Although the Cobra seems similar to the BackBlock in its effects, it employs a different set of dynamics. It compresses the back of the spine, whereas the BackBlock pulls it apart—a fundamental difference between doing the action prone and supine. The exercise increases the arching of the spine, whereas the BackBlock reduces it (although there is a temporary increase initially until the hip flexors lengthen). The Cobra increases the overriding of the facets at the back of the spine whereas through the backward gliding of the vertebrae, the BackBlock disengages the facet surfaces.
The difference in dynamics is profound and this is exactly why the Cobra is so useful—especially in the later stages of treatment when it is used in unison with the BackBlock.
The extreme arching under pressure 'milks' the posterior (back) compartments and helps reduce the swelling of chronically inflamed facets. It also encourages better fluid movement through the discs. Similar to squeezing the rubber knob on the top of a basting tube, you get better suction up the tube if you expel all the air first. The same is true of a stiff and unresponsive motion segment: if it is pressure-evacuated first, you get better separation of both front and back compartments. At the same time, the pressure dints the cartilage covering the facet joint surfaces. As they un-dint, they suck a fluid exchange through the cartilage bed.
The Cobra also keeps the abdominal muscles long. It keeps them from shortening as a result of the vigorous tummy strengthening regimen. Thus the Cobra is a very effective treatment, as long as the segment is not too irritable.
You can beef up the exercise and improve the coordination of the muscles controlling the spine by switching back and forth between the Cobra and the Pose of the Child. This is where you rest your bottom back on your feet and put your forehead on the floor. As you do this, allow your arms to remain stretched out in front of you, draped across the floor. This increases the longitudinal separation through the length of the spine.
The correct way to do the Cobra
• Lie face down on the floor with your legs straight and your hands on the floor beneath your shoulders.
• By straightening the elbows and pushing on the hands, push your upper trunk back off the floor.
• Attempt to straighten the elbows fully but at the same time, try to keep the pubic bone on the floor.
• If you are stiff, let the pelvis lift off the floor so that the body remains suspended. Do not let your hands slide further out to the front so that the pelvis can remain on the floor.
• Try to breathe into the stiffness, letting the spine drop down bit by bit as you remain there.
• Do not let your shoulders come up around your ears. Keep your neck long.
• Hold the position for one minute, breathing quietly as the spine relaxes.
• To come down, bend the elbows and lie the side of your face on the floor.
• Rest for 15 seconds and then repeat three times, trying to get the front of the pelvis as near as possible to the floor.
As a progression:
From the Cobra to the Pose of the Child
• When the hips fall through to the floor with little residual stiffness, you can move into a see-sawing action back and forth.
• Bend the hips by pulling your tummy in hard and pushing your bottom back towards your heels.
• With the top of your feet flat along the floor behind you, nestle your bottom down on your heels.
• Your hands will drag back along the floor a little way; leave them long and relaxed, elbows on the floor.
• Relax the side of your face or your forehead to the floor and remain there for five seconds.
• To rock forwards, slide your hands forward again and after lifting your bottom off your heels, let your hips fall through to the sagging position.
• Count five seconds in this position.
• Repeat four more times back and forth, counting all the time and trying to let the hips drop more each time.
A milder version of the Cobra is the Sphinx exercise, where you lie prone, supported on your forearms, as if reading a book on your tummy. Although it does similar things to the Cobra, it is more effective at reversing a very stooped posture. Your back relaxes more in the Sphinx and thoraco-lumbar jamming can be specifically targeted. It is often painful to start with, as the humped middle part of the spine takes a while to drop through and sag. Your tummy and gluteal muscles may clench automatically to prevent the spine letting go but gradually this eases and the spine drops forward the longer you stay there.
Getting out of the Sphinx is often uncomfortable (even for healthy backs) and you may have to rock your hips from left to right, first gently and then with more gusto, before you can lift your pelvis back from the floor. It may be necessary to roll onto your back and ease your castness by rocking your knees to your chest. This becomes less necessary as your mobility improves. I often manually mobilise stiff thoraco-lumbar spines in the Sphinx position.
The correct way to do the Sphinx
• Lie prone on a carpeted floor with a pillow under your pelvis.
• Push up to support your upper body on both forearms, your elbows directly below your shoulders.
• Let your shoulders relax so your shoulder blades poke out and your spine is free to sag.
• Try to breathe into the stiffness and avoid tensing the spine as it moves through its jammed phase before it drops through to the floor.
• Don't hold onto your spine by tensing the tummy and gluteal muscles. Make them let go so the spine can drop down, one cog at a time.
• Hold the position for one minute and then gently begin to tip your pelvis from left to right in preparation for getting up.
• If you are not too stiff, you can push your bottom back to get up.
• If it hurts too much, roll over onto your back and rock your knees to your chest until the stiffness passes off.
This is the ultimate form of spinal strengthening. It is done face down, off the end of a table, with someone holding your feet as you lower your head to the floor and return to horizontal. It is the big brother to the strengthening part of toe touching in the standing position. But because there is a much longer leverage when the spine is suspended out in mid-air off the end of the table, the muscles work much harder to unfurl the spine. The proper action involves a humping movement of the lower back, followed by a wave-like undulation along the spine, with the head coming up last.
This is a very effective way of building up the strength of all the intrinsic muscles of the spine. Longissimus and iliocostalis are strengthened when they make the lumbar vertebrae slide backwards in a reverse gliding action and multifidus is strengthened when it pulls the tails of the vertebrae to slot them back from their tipped forward position.
As well as being the most effective way of strengthening the intrin-sics, the horizontal exercise is also the most stable. By contrast, toe touches require more advanced coordination. If you have a very unstable segment you never start off from the vertical position, always the horizontal. You may be unlucky enough to get slippage of a vertebra while doing toe touches which will be painful, shake your confidence and leave the problem segment more irritable.
If you want brute strength for a spine which is weak you would go straight to the horizontal form of the intrinsics exercise, doing up to ten repetitions each session. But if you want to gradually build up the strength of a very weak, poorly controlled segment, you have to start off doing just one or two horizontal intrinsics each time. These strengthen the segment in its most stable position and then as control builds up, you progress to the toe touches from a standing position. By then the reaction time will have improved in the deep muscles and the defense mechanisms of the weak segment will be more advanced. When the general level of irritability of the problem segment is on the wane, the horizontal intrinsics provide the higher levels of strength and endurance.
Spinal intrinsics should never be done more often than once every week to ten days, otherwise your back will remain sore. The strenuous segment-shutting action of multifidus at the back of the interspaces can act as an irritant which keeps the back inflamed. Always follow each session with lengthy periods of knees rocking and spinal rolling but if your back takes more than a few days to settle, you should reduce the number of repetitions from ten to five. If the reaction is still too extreme, then you should extend the time period between sessions to two, possibly three weeks. You can only strengthen the muscles around a weak segment at the rate it can take it, otherwise your back will remain angrily on guard and you will sense no improvement at all.
The correct way to do spinal intrinsics strengthening
• Lie face down on a firm surface such as a sturdy table.
• Place a pillow at the edge of the table and with somebody holding your feet, move up the table so your two hip bones are on the pillow.
• Allow your upper body to drop down towards the floor, putting a hand out to take your weight on the floor.
• Fold your arms across your chest and let your upper body hang down, making an angle of 90° at the hips.
• From this starting position, tighten your buttocks and pull your tummy in, rolling your pelvis back.
• Continuing this very powerful contraction, unfurl along the length of your spine one vertebra at a time, with your head coming up last. Do not attempt to hyperextend beyond the horizontal position.
• To return to the floor, duck the head down and do the movement in reverse.
• At the bottom of the cycle, hang for a moment, completely relaxed, before continuing.
• Repeat ten times, but less if your back reacts after each session.
As a progression:
• Increase the leverage and make the exercise more difficult by interlacing the fingers behind the neck with the elbows wide.
• Unfurl to horizontal but do not hyperextend beyond that line.
• You may do six of this version and as your back tires, go back to folding your arms on the chest for the other six.
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