Spinal Health and Common Sense

Ageing spines are part of the human condition, and most of us can expect spinal pain at some point. Thankfully, these episodes are mostly self-limiting: most people improve substantially within 6 to 8 weeks, although some may have lingering or recurring symptoms. This is my personal advice on looking after your spine: what helps, what doesn’t, and why some of it may surprise you.

Prof Nick Kruger · Orthopaedic spinal surgeon, Cape Town

Why do our spines start to hurt in our 40s?

Our spines are very well designed to give service for roughly 35 years. In evolutionary terms that is enough: we are adult at 18, able to raise a family, and once our offspring are mature we become non-essential. Human longevity is a product of civilisation. We no longer die of exposure, starvation, predators or disease, but we are left with an ageing spinal column which, having done its job perfectly well in getting us to adulthood, is now past its sell-by date.

So it is no surprise that backs and necks tend to give trouble from around 35 to 40, in the prime of our productive lives. Spinal pain usually peaks in the middle decades and starts to settle after 50 to 60, even though the degeneration itself keeps progressing. As discs dry out, joint cartilage thins, bone spurs form and the spine stiffens, the pain often settles.

Most treatments don’t beat time

A wide variety of practitioners are consulted for back and neck pain: medication, physiotherapy, chiropractic, acupuncture, massage, aromatherapy and exercise programmes, among others. Very few remedies are proven to work. Most spinal pain improves in line with its natural history, over 6 to 8 weeks, whatever the treatment. These therapies don’t particularly do better than time, but they can provide reassurance and comfort and help manage symptoms while the pain settles naturally.

Where my view differs: the myth of core stability

A popular belief is that a painful spine needs to be kept supple and supported by strong “core muscles”, and that pain develops because the core is weak, out of balance or posture is poor. This has no scientific basis, and some publications are critical of the idea (Lederman, “The myth of core stability”, Journal of Bodywork and Movement Therapies 2010).

I regularly see fitness instructors, CrossFit champions, bodybuilders, yoga and Pilates instructors and elite athletes whose muscle strength and conditioning are at their peak, yet who have advanced spinal degeneration and painful arthritic joints. High-impact sportsmen such as rugby players have marked degenerative changes despite massive core muscles. Like a car tyre, a disc wears out roughly in proportion to the loading it endures.

Let arthritic joints settle

In orthopaedics, a painful arthritic joint is not treated by prescribing movement and muscle strengthening. It is rested, splinted, fused or replaced, as is routine for knees and hips. There are no programmes that make an arthritic knee less painful by strengthening the quadriceps and hamstrings, yet against these principles we manage spinal joints with stretching and strengthening. A joint, like a wheel bearing, cannot un-degenerate itself with movement and muscle training.

My somewhat controversial advice is to follow nature’s lead and let arthritic spinal joints stiffen and settle. Ankylosing spondylitis is a good example: it is painful while the joints are being destroyed, but once the spine auto-fuses it becomes rigid and painless. Spinal fusion surgery works on the same principle. So I don’t advise trunk exercises, stretching or loading activities. Even isometric exercises load and unload the spine. Your back will not become “stiff” from not stretching, any more than your knees do. Normal daily activity is enough.

Exercise: non-impact cardio is the best medicine

Far from avoiding exercise, I am a firm advocate of it, but it should be exercise that does not load or move the spine unnecessarily. Cardiovascular exercise is the best option and does far more than strengthen muscle: it releases endorphins that lift mood and modulate pain, helps weight loss, improves metabolic conditions such as high blood pressure and diabetes, and influences the immune system.

• Choose non-impact cardio such as spinning, stationary cycling or swimming. The specific exercise matters less than doing it without pain during or after the activity.
• Get your heart rate up. The benefits, including endorphin release, come from exercising hard enough: aim for around 75 to 80% of your predicted maximum heart rate (roughly 220 minus your age).
• Make it sustainable, and keep it up for life.

Weight, diet and smoking

A weight-loss programme is probably the most understated treatment for back pain. Fat tissue produces inflammatory chemicals (adipokines) that are linked to disc degeneration, osteoarthritis and heart disease, so the spine is affected by the same processes as the cardiovascular system. Losing weight is difficult with our westernised diet of cheap carbohydrates; my personal recommendation is the South Beach diet, which seems more sustainable. Stopping smoking and keeping a normal body mass index complete the picture.

Where this advice applies: it is aimed at people with mechanical back or neck pain who have not improved despite the usual advice and treatment. If you have warning signs such as leg weakness, numbness in the saddle area, bladder or bowel changes, fever or unexplained weight loss, please seek medical attention promptly.

References and further reading

Published research that supports the points made in this article, grouped by topic: natural history, prevention, core stability, spinal loading, cardio and endorphins, and weight, inflammation and smoking.

1. Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ 2003;327:323. Link
2. Burton AK, Balagué F, Cardon G, et al. European guidelines for prevention in low back pain. Eur Spine J 2006;15(Suppl 2):S136–S168.
3. Steffens D, Maher CG, Pereira LS, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med 2016;176(2):199–208. Link
4. Lederman E. The myth of core stability. J Bodyw Mov Ther 2010;14(1):84–98.
5. Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord 2014;15:416. Link
6. Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for chronic non-specific low-back pain. Cochrane Database Syst Rev 2016;(1):CD012004. Link
7. Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. Br J Sports Med 2003;37(3):263–266. Link
8. Disc degeneration on MRI is more prevalent in young elite skiers compared to controls. Eur Spine J 2018. Link
9. Luoma K, Vehmas T, Raininko R, Luukkonen R, Riihimäki H. Lumbosacral transitional vertebra: relation to disc degeneration and low back pain. Spine 2004;29(2):200–205. Link
10. Meng XG, Yue SW. Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis. Am J Phys Med Rehabil 2015;94(5):358–365. Link
11. Goldfarb AH, Jamurtas AZ. β-Endorphin response to exercise: an update. Sports Med 1997;24(1):8–16.
12. Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol 2010;171(2):135–154.
13. Wang T, He C. Pro-inflammatory cytokines: the link between obesity and osteoarthritis. Cytokine Growth Factor Rev 2018;44:38–50.
14. van den Berg R, Jongbloed LM, de Schepper EIT, et al. The association between pro-inflammatory biomarkers and nonspecific low back pain: a systematic review. Spine J 2018;18(11):2140–2151.
15. Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Am J Med 2010;123(1):87.e7–87.e35. Link

These are my personal opinions, based on years of managing spinal patients who have failed conventional treatment and a thorough understanding of spinal biomechanics. There is some literature support for these concepts, but ultimately the evidence is mostly anecdotal, and there is also no good evidence for any other approach.