The spinal column is at the center of human movement and, all too often, at the center of human pain and discomfort. In fact, statistics show that 4 in 5 Americans will suffer from back pain during their life span, making a healthy spine a priority (Cleveland Clinic 2021).
Now, with twice as many people working from home as pre-pandemic—often in nonergonomic setups—chiropractors and other health professionals are seeing more back problems than ever (Trivedi 2020; ETR+ 2020). This may explain why the International Association for the Study of Pain has named 2021 the Global Year About Back Pain (IASP 2021).
The most effective way to prevent lower-back pain will come as no surprise to fitness professionals: It’s exercise for a healthy spine. “Ergonomic interventions, such as lumbar supports, lifting devices, workplace modification, job rotation and modifications to production systems, appear less effective than exercise in preventing occupational back pain,” said Dr. Owen Williamson, co-chair of the IASP initiative (IASP 2021).
Creating exercise programs for a healthy spine that support stability, proper posture and strong spinal musculature is important for optimizing client health. And in training sessions, fitness pros need to take time to evaluate the way clients stand, walk, sit and move.
Basic Anatomy of the Spine
The spine is a powerful column of interconnected and interwoven bones, joints, nerves, tendons, ligaments and muscles. In keeping with the spine’s natural curvature, the 33 vertebrae are categorized as cervical (neck), thoracic (upper torso), lumbar (lower back), sacral (pelvic girdle) and coccygeal (tailbone). These have 7, 12, 5, 5 and 4 vertebrae, respectively, though the sets found in the sacrum and coccyx are fused before birth (Cleveland Clinic 2021).
The Curves of a Healthy Spine
A healthy spine has both outward curves and inward curves, allowing the spine to act like a spring structure. Too much exaggeration in any curve increases the risk of injury.
The spine’s three main curves create an S-shape when viewed from the side. These curves are called cervical lordosis, thoracic kyphosis and lumbar lordosis.
As human beings, we want to protect and maintain the natural S-curve of the spine, with the cervical and lumbar sections curving slightly inward and the thoracic spine curving outward. This natural curvature is often referred to as a “neutral spine.” Maintaining a neutral spine distributes body weight evenly, protecting all parts of the spinal column from undue stress (UMMS 2003). A neutral spine also allows for efficient movement and a healthier physical appearance overall.
How Muscles Maintain a Healthy Spine
Muscles help with every function of the body and provide the strength and stability needed for good posture and proper alignment.
Three types of muscles that support the spine are extensors (back muscles and gluteals), flexors (abdominals and iliopsoas muscles), and obliques, or rotators (side-body muscles).
When muscles work together (co-contract) to stabilize the spine and maintain its natural S-curve, they pull in different directions with little tension. However, if a muscle or group of muscles pulls in one direction with too much force or for too much time, the spinal column may start to move out of its healthy curves and could potentially remain in misalignment. On the other hand, when muscle strength and flexibility of the front, back and side bodies are in balance, it is more possible to co-contract the muscles needed for lengthening the spine.
An elongated spine enhances posture and makes it easier to move and perform daily activities. With coordinated contraction of surrounding muscles, the spine can lengthen from a slouched, increased curve to a natural S-curve. To help clients achieve the lengthened natural curve, fit pros should include cues on co-contracting muscles in different areas of the spine during exercises. Performing movements that lengthen the spine will also reduce internal pressure on the disks.
Understanding Movement of the Spine
Our bodies should move in a way that supports the natural curves of the spine. Moving with proper body mechanics assists with optimal stability and protection of the spine. Understanding how the spine moves makes it simpler to understand its limitations. In your own work with clients, this understanding will enable you to cue and correct exercises more effectively.
Though the vertebrae of the sacrum and coccyx (tailbone) are fused, the others are connected by facet joints that allow movement in multiple directions at the same time (CCSI 2021a). Movements between individual vertebrae tend to be small, but the cumulative action of all these movements gives the spine a greater range of motion. Limitations in movement are due to the orientation of the joints and ribs, as well as the spine’s natural curve (UMMS 2003).
Flexion and extension (bending forward and back) are both greatest in the cervical spine and lumbar spine. They are more limited in the thoracic spine due to the ribs.
Lateral flexion (side-to-side bending) is greatest in the cervical and lumbar spine and again more limited in the thoracic spine.
Rotation (torso twisting) is freer in the thoracic and cervical spine and limited in the lumbar spine.
These factors are important considerations when choosing and cuing exercises involving the spine. For example, crunches lying supine have a flexion limitation. Cue the exercise by asking your client to lift the shoulders and head off the ground, but don’t make flexing the spine the focus. Instead, cue contraction of the abdominals for a more intense workout.
Pelvis Position for a Healthy Spine
According to Karen Clippinger, MS, author of Dance Anatomy and Kinesiology (Human Kinetics 2007), sitting slumped in a chair is associated with as much as 40 degrees of posterior pelvic tilt. This posture, if habitual, will decrease curvature in the lower back (lumbar lordosis) and create a greater curve in the upper back (thoracic kyphosis).
In the ideal sitting position, body weight falls directly over the pelvis so that the lower part of the gluteus maximus is bearing the weight and the person is sitting on the ischial tuberosities, often called the “sit bones” or “sitz bones.” The lower back should appear lengthened, not rounded. The goal is to achieve a neutral pelvis position because this optimizes strength and muscle balance, giving the spine maximum protection. Aligning the pelvis, ribs and head is also important for an upright posture.
Anterior and Posterior Tilt
When there is an anterior pelvic tilt, the top of the pelvis rotates forward, and you may see an excessive arch in the lower back (lumbar lordosis). When this happens, the hip flexors and quadriceps are usually tight, and the hip extensors lengthen and become weak. Abdominals and gluteals may also be weak (MBM 2021).
When there is a posterior pelvic tilt, the top of the pelvis rotates back, and you may see a flattened lower back with the gluteus maximus tucked under. When the body is supine on the floor, there will be no space between the lower back and the floor. Tight hamstrings, glutes and abdominals pull the pelvis up. When the pelvis is in a posterior tilt, the lower-back muscles are usually weak.
Here are two ways to help a client do a posture check and correct an improper pelvic tilt:
Look at the Hip Bones
In the ideal position, the two hip points (anterior superior iliac spines) and the pubic bone are in the same plane. When the client is standing, the hip points and pubic bone should line up vertically.
Don’t Spill the Water
When the client is lying supine, the hip points and pubic bone should line up horizontally. To check this, have the client lie supine and imagine balancing a cup of water on the lower abdominals. If the cup of water is balanced and does not spill toward the client’s head (posterior tilt) or toward the client’s feet (anterior tilt), then the client is most likely in a neutral pelvis position.
The neutral position of the pelvis creates a strong, stable base for support and is the safest position for the spine.
Correcting Misalignments for a Healthy Spine
There are multiple misalignments, but there are three particularly common ones that you should address with clients: cervical lordosis, thoracic kyphosis and lumbar lordosis. While these are all natural curves of the spine, each of them, when excessive, can increase injury risk and possibly lead to pain (Czaprowski et al. 2018). Addressing a mild misalignment early on can prevent more serious misalignment problems down the road.
The Cervical Spine
The cervical spine’s main function is to balance the head. In the ideal position, the cervical spine lines up with the thoracic spine.
A possible cause of cervical misalignment is use of cell phones and computers. Misalignment of the cervical spine should be addressed in all exercises.
Try this: When the client is in a pushup, place your forearm on the client’s back with your elbow at the midback and your hand hovering over the client’s head. Rest your arm on the thoracic spine.
Often, the head will be down and away from your hand. If so, ask your client to raise the head until the back of it touches your hand.
By contrast, if the head is looking up, the client is extending and compressing the cervical spine. In this case, cue the client to lower the head and look straight down at the floor.
The Shoulder Girdle
Shoulders should be down and back. Posterior muscles must be engaged to stabilize and maintain proper alignment in the shoulder area.
Don’t let a client’s shoulders round forward during exercises. This can eventually affect the entire spine. The large muscles of the back, neck and shoulders—the trapezius, latissimus dorsi and smaller rhomboids—are usually weak when you see rounded shoulders.
Try this: Ask your client to relax the neck, allowing the trapezius to relax, and then gently slide the shoulders down and back. You can also add exercises that open the chest and engage those weak muscles.
See also: Prep the Shoulders Before Play
The Thoracic Spine
The job of the thoracic spine is to hold the rib cage and protect the lungs. The midback should have a slight natural curve, but if excessive (rounded back), it is important not to exacerbate this in workouts. For example, pushups, cat pose in yoga, and other forward-facing movements can encourage rounding of the back.
Try this: Incorporate exercises to strengthen the back body and open up the front body. Chest flies, rows and quadruped trunk rotations can help counter the problem.
The Lumbar Spine
The main purpose of the lumbar spine is to hold the body’s weight. Misalignment in the lower back seems to be common today. Sitting for long periods of time or standing and moving incorrectly may cause lower-back problems and misalignment.
Try this: Many times, a posterior pelvic tilt will place stress on the lower back. To bring the pelvis into a more neutral position, use suggestions from earlier in the article (left).
For a Healthy Spine, Go Back to Basics
Today we have lots of choices in how we exercise to stay fit. However, the basics are the same when it comes to cuing clients on maintaining a healthy spine. Most exercises should be performed with a neutral spine and with the muscles working together to support the move.
As you observe your clients moving through any type of exercise, scan them from head to toe with the spine in mind. While new equipment and creative modalities may create a more interesting and fun fitness routine, clients who are missing that healthy S-curve will likely benefit more from going back to basic moves designed to realign their spine.
All Your Options for a Healthy Spine
Cardiovascular workouts, flexibility programming and strength training probably come to mind when you think about exercising to maintain health and fitness. A cardiovascular workout helps with circulation, is important for a healthy heart and lungs, and usually feels good! Flexibility promotes a sense of freedom in movement that allows everyday activities to be performed with ease. Strength training helps develop a strong body with balance and stability. Interestingly, all of these are important forms of exercise for spine health, too (CCSI 2021b).
Cardiovascular exercise is important for overall well-being and can be a great choice of exercise for strengthening the spine. This type of movement offers the benefit of weight loss and helps maintain a healthy body weight that the spine can support. According to UWhealth.org, exercises that are good for the heart are good for the spine. The natural S-curve of the spine is there to help absorb impact. So encourage clients to run, walk or perform any other type of cardiovascular exercise they enjoy (UW Health 2016).
Flexibility exercises can make it easier for the body to move into positions needed for optimal strength and alignment. For all major muscle-tendon groups—neck, shoulders, chest, trunk, lower back, hips, legs and ankles—ensure your clients stretch at least two or three times a week (Page 2012).
Strengthening exercises will support the spine if performed with a goal of maintaining muscle balance. If exercises regularly work the anterior muscles and not the posterior muscles, imbalances will develop over time. To create balanced workouts that support a neutral spine, consider every muscle in the body.
Stand more, sleep more. Recovery and everyday movement are important, too. In an article titled “Back Pain? What’s Good for the Heart is Good for the Spine,” James Leonard, DO, PT, co-director of the UW Health Spine Center, highlighted two other factors that can exacerbate spine pain: sitting for too many hours per day and sleeping for too few (UW Health 2016). If your clients need to sit for long periods of time, remind them to get up every hour and move around a bit. And encourage them to aim for 8 hours of sleep per night to recharge the spine—and their whole being.
Assess a client’s posture before diving into program design. Pay attention to spinal positioning during movement.
CCSI (Colorado Comprehensive Spine Institute). 2021a. Understanding spinal anatomy: Facet joints. Accessed Feb. 25, 2021: coloradospineinstitute.com/education/anatomy/facet-joints/.
CCSI. 2021b. Exercise for a healthy spine. Accessed Feb. 25, 2021: coloradospineinstitute.com/education/wellness/exercise-healthy-spine.
Cleveland Clinic. 2021. Spine structure and function. Accessed Feb. 24, 2021: my.clevelandclinic.org/health/articles/10040-spine-structure-and-function.
Czaprowski, D., et al. 2018. Non-structural misalignments of body posture in the sagittal plane. Scoliosis and Spinal Disorders, 13 (6).
ETR+. 2020. COVID-19 survey: Permanent remote positions double and productivity improves? Accessed Feb. 25, 2021: etr.plus/articles/covid19-doubles-permanent-wfh-improves-productivity.
IASP (International Association for the Study of Pain). 2021. 2021 Global Year About Back Pain: Interview with the co-chair: A conversation with Dr. Owen Williamson. Accessed Feb. 24, 2021: iasp-pain.org/GlobalYear/2021CoChairWilliamson.
MBM (Manchester-Bedford Myoskeletal). 2021. Pelvic tilt. Accessed Feb. 25, 2021. mbmyoskeletal.com/learning/pelvic-tilt/.
Page, P. 2012. Current concepts in muscle stretching for exercise and rehabilitation. International Journal of Sports Physical Therapy, 7 (1), 109–19.
Trivedi, K. 2020. Back and spine: Working at home can be a pain in the neck and back. Accessed Feb. 24, 2021: utswmed.org/medblog/work-from-home-coronavirus-back-neck-pain/.
UMMS (University of Maryland Medical System). 2003. A patient’s guide to anatomy and function of the spine. Accessed Feb. 25, 2021: umms.org/ummc/health-services/orthopedics/services/spine/patient-guides/anatomy-function#:~:text=The%20spinal%20cord%20is%20a,to%20live%20an%20active%20life.
UW Health. 2016. Back pain? What’s good for the heart is good for the spine. Accessed Feb. 12, 2021: uwhealth.org/health-wellness/back-pain-whats-good-for-the-heart-is-good-for-the-spine/48955.
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