Easing spinal compression - spinal stenosis

Easing spinal compression/spinal stenosis

With the inevitability pushing down of gravity we can expect some spinal compression as part of the natural ageing process, but what happens when this tips over into pathology and pain? With more and more people suffering back pain, some understanding of where the design of our spine meets how we move – and modern postural patterns – may help us find space and relief at our central axis. 

The human spine is curved (see fig.1) in an s-shape and this is an important design for our bipedal (two-legged) upright sitting or standing stance; it allows the weight distribution to shift as we move and hold our head and organs vertically up from the ground.

Our spines consist of 24 individual sections of bone (vertebrae) with rubbery discs in between to keep them separate and the whole spinal column freely mobile. This also creates space for the spinal canal, a cavity running through each of the vertebrae, which encloses the spinal cord, spinal nerves, ligaments, fat and blood vessels. Spinal nerves exit the spinal canal through nerve root canals (intervertebral foramen) to branch out into your whole body. Both of these canals are surrounded by bone and ligaments, where changes in the bone structure can narrow them and create compression or restriction of the spinal cord or nerves. Pain can occur when blood flow is the restricted out to limbs and can be dull and aching or sharp in nature.

Whilst it is quite normal for our spinal canals to narrow with age, spinal stenosis (fig.2) is a progressive degenerative condition that over time, where any combination of bone spurs, enlarged facet joints or bulging discs constrict the nerve root canals causing compression and entrapment of the spinal nerves and even the spinal cord with central stenosis.  It can occur along any area of the spine; neck (cervical), upper back (thoracic) or most commonly the lower back (lumbar). We can see from fig.3 that modern postural patterns away from our ideal alignment (A) can create compression in different ways for individual tendencies.

Spinal stenosis is most commonly caused by changes in the spine related to osteoarthritis and often accompanies herniated discs (see fig.4) where a portion of the inner soft centre (nucleus) of the disc pushes through the harder exterior (annulus). Symptoms of spinal stenosis follow if the herniation compresses a nerve.

Where modern postural habits such as sitting for long periods of time are inherently compressive for the spine, some people with spinal stenosis may not be aware of its presence or experience any symptoms. Beginning signs to notice are pain, tingling, numbness and muscle weakness; pain that warrants investigation spinal stenosis is present is relieved by rest or bending forward where the spine is flexed and worsened by spine extension or bending backwards. When it affects the cervical spine (neck) symptoms are usually felt in the arms and with the lower back, most often in the legs Symptoms can worsen over time, with loss of bladder and bowel control for the most severe cases involving the lower back.

The medical opinion may be that there is ‘no cure’ and spinal ‘decompression’ surgery has been offered. This is mostly laminectomy that removes the lamina, the posterior (back) part of a vertebra (spinal section) that covers your spinal canal and is most commonly performed in the lumbar area or the lower back. This essentially enlarges the spinal canal to relieve pressure on the spinal cord or nerves, but according to a 2017 review in the International Journal of Surgery (Int J Surg., 2017;44:329-338) comes with a significantly greater risk of complications than those seen with physical therapy programmes. Risks with surgery include recurrent or continuing symptoms, infection, blood clots, leakage of cerebrospinal fluid, nerve injury, paralysis and loss of vision.

Patients are also routinely offered high dose pain medication for the inflammatory effects that create chronic back and leg pain, as the nerves feeding down into the legs are impinged. Physiotherapy may be advised to help increase the spinal range of motion (ROM) and ensure that sufferers do not avoid motion. As the pain can cause trepidation around movement, this can feel like an understandable self-protection, but further loss of ROM can heighten symptoms. Our myofascia (muscle and connective tissue) in all areas – including around the spine - need constant motion to feed nutrients and oxygen, as well as remove waste products from any area of the body. This always keep tissues hydrated and less prone to adhesions; hardened tissues that add to inflammation and have shown to be root sources of pain that may be transmitted to other areas too (Curr Pain Headache Rep. 2013;17(8):352).

Building reliance on pain medication can worsen the situation as it not only reduces the gut bacteria and increases signalling of inflammatory pathways (Clin Microbiol Infect. 2016;22(2):178.e1–178.e9), but also masks the pain that informs us how best to move. If we cannot feel nerve compression, we can keep pressing into it; rather developing a compassionate, mindful relationship to the pain – it is good to seek a mindfulness course or individual guidance – can allow you to listen to its voices and respond with curiosity and exploration. This is where you have an opportunity to help your body as it needs, without judgement or criticism.

Those with spinal stenosis have been historically only been recommended bending the spine forward, putting it into flexion. This was believed to relieve nerve pressure by increasing the diameter of the spinal canal. However, to move in one direction without the balance of the opposite is to restrict full motion of the body. The sequence here includes some gentle back bending, because although deeper back arches can put too much pressure onto discs that may be herniated (closing the spinal canal further), gently pressing there can move nerves away from the spinal canal, offering them more space and helping relieve compression.

Encouraging healthy posture with natural spinal curves relies on balance between the front and back body, so becoming aware of both of those as we open the spine front and back, can also help inform the way we move in daily life. Ultimately, if you can feel uplift through the spine whenever possible, there is less nerve impingement. Strengthening the musculature that supports the spine upwards also creates the space that relieves compression.

Exercises for relieving spinal compression

These exercises are mostly isometric in nature – where muscles contract, but don’t actually move ie they hold us in place with muscle fibres activated but with equal forces working against each other. This creates a strengthening effect and without the exertion of movement also allows us to breathe fully and does not contribute to any stress response which fires off protective, inflammatory reactions.

The most important guide within these exercises is to listen and respond to what feels right for your body at any given time. If you find any posture aggravates symptoms or sets off internal alarm bells, back out to a place where it feels you can soften and breathe with the physical sensations. If there is no position along the way towards the end point that feels happy and safe, stop doing that exercise. However, with each final position here is a gentle pulsing motion to help the myofascia become more pliable in that direction. You can explore that to help loosen tissues locked into patterns that may exacerbate symptoms.

Some side-bending and twisting is included, where moving away from the source of pain can decrease pressure on nerve roots for those with lateral stenosis. So if the pain is on the right, a bend or twist to the left may make space on the right-hand side and relieve pressure and pain there. Taking to the left would then need to be done very gently with deep listening and feeling out the range of motion, which may differ greatly to the right.

The exercises are floor-based, to encourage the spine intelligence to finish with a short or long walk to allow natural motion and side-to-side motions of the spine, freeing up through the chest and shoulders. It can also be used to create space in the spine in preparation for other exercises.

Spinal fluidity

• From lying, feet hip-width or wider, as you inhale and raise the pelvis into a bridge pose, lift into the chest rather than the lower back. You don’t need to come up far, start halfway to gauge the sensations and feel the support of drawing up the belly. Your arms can come up and over the shoulders to reach above your head (as shown) or stay down by your hips as the pelvis lifts – each has different sensations in the back and spine, so see what suits you.
• On the exhale, lower the spine back down, vertebra by vertebra.
• Lift up and down, eventually holding the pose up for as long as you feel neither stress nor strain in the body or breath.
• Roll to your side to counter the pose with the gentle forward bend of a side-lying foetal position.

Exploring your spinal range of motion

• Sit in a‘z-legs’position, with the left leg bent in and the right bent out in a wide seat and the left hand to the ground. Lift the right arm, bent so that the lower arm is parallel to the ground. Inhale length in the spine and exhale to twist to the left, continuing this motion comfortably.
• Then either with the left elbow or hand on the ground, take the right arm up to where you can comfortably breathe easily as you lengthen the right side of the body and spine. This may be up by the right ear, reaching out at shoulder height or lower if need be.
• Come to the other side, respecting different needs on each side.

Spine suspended on all-fours

• On all-fours begin moving into shoulders and hips to tune in to how you feel around the spine. Gently ‘wag your tail’ from side-to-side for a little lateral motion.
• From a central position, with the inhale arch your back just as much as you easily open the chest without pain.
• With the exhale, draw your belly in to arch your back and open the back body. Move between these two to alternatively find space front and back of the spine.

Bringing intelligent length into your spine

• From all-fours, tuck the toes under and lift the hips. As you exhale, bring shoulders over wrists, coming right up onto the balls of the feet. Draw the chin into the chest, rounding the back and gathering the belly into the body.
• On the inhalation draw the thighs back towards downwards-facing dog, opening the front body, so knees may be bent and heels high; in this way coaxing out the pose with a rocking rhythm back and forth.
• In this way, if you settle into downwards-facing dog pose you can retain length in the spine and notice if tightness in the back of the legs or top of the back limits that length. If so, keep the heels high so you can still retain openness in the chest.

Opening the front body

• Either from all-fours or downwards-facing dog, step your right foot forward so it is pointing straight ahead. From this lunge, bring your left hand onto your belly and right onto your lower back; here feeling how you support uplift through the front and softening down the back.
• Taking the left hand to the outside of the right thigh, lift the left arm with elbow bent so the forearm follows the line of the collarbone. Then inhale into a twist and exhale to retract back again. Move to the other side.

Gentle resting spine flexion

Resting the back in a gentle forward bend allows you to integrate the previous movements and a place to come to relieve pressure at any time. A foetal position with feet on floor or legs lengthened out (knees out to the sides) allows you to fully rest and breathe kindness to your body there.

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