Journal of Bodywork & Movement Therapies (2009) 13, 350e361

PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

PREVENTION & REHABILITATION

The neutral spine principle

Matt Wallden ND, DO, Associate editor
Received 5 July 2009; accepted 8 July 2009

KEYWORDS
Neutral spine principle;
Spinal rehabilitation;
Spinal conditioning;
Spinal strength;
Conditioning

In any aspect of life to have principles can aid in the (2) A basic or essential quality or element determining
simplification of complex scenarios. All too often, princi- intrinsic nature or characteristic behavior
ples can be easily mislaid when the detail of a situation (3) A rule or law concerning the functioning of natural
becomes consuming. Such micromanagement, whilst in phenomena or mechanical processes
itself not problematic, in the absence of principles
becomes extremely confusing; the outcome commonly Like any assumption, a principle should be tested as
being paralysis by analysis. far as it allows. There are various ways to test a prin-
Some examples of useful (though not universally accepted) ciple. It can be isolated and tested in isolation; how
principles in bodywork and movement therapies could include many people with non-neutral curves have back pain,
the SAID principle (Baechle and Earle, 2000; Chek, 2001), versus how many with neutral curves, and how many
the principle of movement emanating from the core from each group are in pain. Alternatively, it can be
(Gracovetsky, 1988; Chek, 2001; Richardson et al., 2004), the tested in a real-world environment with multiple other
form principle (Baechle and Earle, 2000; Chek, 2001), the interacting factors. Either of these environments may or
principle of structure function inter-relationship (Ward, may not reveal the truth or the falsehood of the
1997), the principle of balance or the Yin-Yang principle (Hicks assumption that maintaining a neutral spinal position is
et al., 2004), or the topic of this editorial, the neutral spine optimal; in which case, the only thing that can serve us is
principle (Baechle and Earle, 2000; Chek, 2001; Lee, 2004; the experience of using it.
McGill, 2002, 2007). Ultimately, it may be worth considering that unless
a better principle replaces the principle under scrutiny,
that principle remains in the ascendency.
What exactly is a principle?

The word ‘‘principle’’ (according to http://www. What exactly is neutral?

thefreedictionary.com/principle) may be defined as:
Neutral literally means unpolarised. When the spine moves
(1) A basic truth, law, or assumption into flexion it is moving out of neutral, when it moves into
extension, it moves out of neutral. Indeed any ‘‘motion
vector’’ which moves the spine away from its optimal
E-mail address: [email protected]. postural position could be considered a non-neutral spine.

1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2009.07.006
Neutral spine 351

PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

In this way, it might be easier to classify what neutral isn’t If the neutral zone is defined as a small range of
rather than what it is! movement near the joint’s neutral position where minimal
resistance is given by the osteoligamentous structures
Where exactly is neutral? (Lee, 2004), then a spine which has been held in a position
of relative flexion for 15 or 20 years, for example, will have
As far as any joint is concerned, the neutral position may be a neutral zone that has migrated anteriorly, compared to
defined as one in which the joints and surrounding passive someone who has maintained a neutral spine during that
tissues are in elastic equilibrium and thus at an angle of same time frame.
minimal joint load (McGill, 2007). Other factors that may
be considered as part of the definition include: the holding The neutral spine principle
of a position in space in which translation of load is optimal
through the structures of weight bearing, and/or where the The neutral spine principle is a rehabilitative and perfor-
lengthetension relationships about the motion segment(s) mance conditioning principle (Lee, 2004; Comerford and
are balanced, and/or where the optimal instantaneous Mottram, 2001; McGill, 2002; Chek, 2001; Baechle and
axis of rotation can be maintained within the motion Earle, 2000) which suggests that in early stage rehabilita-
segment(s). Describing neutral provides a similar challenge tion and the learning phase, postural conditioning,
to defining posture; ‘‘the position from which movement strength-endurance, and strength development phases of
begins and ends’’ being as good as any. So this is why conditioning, the capacity to both maintain a neutral spine,
Panjabi (1992) and others have opted to describe and to be able to dissociate the spine from the hips, is
a ‘‘neutral zone’’. a foundational movement skill.

The neutral zone

Why should being in a neutral spine
The neutral zone can be defined as a small range of movement be of any benefit?
near the joint’s neutral position where minimal resistance is
given by the osteoligamentous structures (Lee, 2004). In Different authors and researchers have attempted to esti-
other words, it is a constantly moving position of a living joint, mate how the loading of the motion segment (the disc and
which is characterized by creating the least possible stress to facet joints) should be shared in a functional spine.
the surrounding passive subsystem of that joint. Adams et al, (2006). describe weight bearing through the
spine and indicate that some early research suggested that
Out of neutral the zygapophyseal (facet) joints carried approximately 20%
of the load and the disc 80%. More recent studies have sug-
gested that the facet joints can bear up to 40% of the applied
What happens if the joint is out of neutral? In the first
load, while other researchers have suggested that, in the
instance, very little should ‘‘happen’’; simply the tissues on
lumbar spine at least, the facet surface orientation means
one side of the joint will be in a relatively shortened/
that no weight can be borne through these structures. This
compressively loaded position, while the tissues on the
will be further discussed below (Figures 1 and 2).
opposite side of the joint will be in a relatively lengthened,
distractively loaded position.
Under natural conditions, the result of this is that the
nervous system is made aware of this imbalance via the
type 1 mechanoreceptors, which communicate directly
with the tonic (inner unit) musculature around the joint and
encourage a return toward neutral. However, under not-so-
natural conditions of forced concentration in front of
a computer screen, or at a desk, deadlines, targets, or
under the influence of social or pharmaceutical drugs
(among many other examples), the nervous system may not
respond in the way it should, i.e. to correct the imbalance.
If this occurs then, across time, the shortened
compressed tissues will undergo dehydration, contracture,
will shorten and become less able to translate loads, while
the lengthened, tractioned tissues will also undergo dehy-
dration, creep, will lengthen and will lose tensile strength
(McGill, 2002), and will become less effective at passively
restricting excessive movement at the joint, and conse-
quently may lose mechanoreceptive efficacy.

Neutral zone concerns Figure 1 The spine has classically been viewed as a tripod
mechanism with the anterior pillar consisting of the discs and
This raises some concerns with respect to the concept (or vertebral bodies, and the posterior pillars being the facet
perhaps just the definition) of a ‘‘neutral zone’’. joints.
 352 M. Wallden
PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

these claims; especially if they recognized that the disc will

withstand loading at greater intensities than the bones
themselves can handle and, indeed, remained intact after
all the vertebrae had been reduced to a series of crush
fractures in research on monkeys (Gracovetsky, 2003). So
Facet Disc how is it that picking up a pencil, or bout of hay fever can
rupture a healthy disc?
This seems implausible based on our knowledge of disc
strength.
Nevertheless, a pencil or a sneeze may become the
proverbial straw that breaks camel’s back in an unhealthy
disc. That last little bit of stress to an already severely
compromised and weakened tissue means that even
a pencil or a draught can become ‘‘the last straw’’ as far as
the spine is concerned.
How might such a process of cumulative microtrauma
result in such a significant weakening of the immense
tensile strength of the annulus of the disc, for example?
This is an important question, as it is clear that the disc
Figure 2 When there is greater flexion in the spine, there is is an incredible translator of mechanical forces. So, how
greater loading on the disc, while when there is greater could simply sitting with a flat-backed posture, even for
extension in the spine the load shifts toward the facets. a number of years, result in a breakdown of the annulus
Maintaining a neutral spine is the best way to load share fibrosis; a structure which not only has its own immense
between the 3 pillars of the tripod mechanism. strength, but that is swaddled in paraspinal ligaments
which can withstand loads of up to 1260 kg (Kerr, 1999) per
square centimeter; a tensile strength greater than steel?
The implication, then, is that if too much of the loading
Compare this to the 5 kg per square centimeter (Kerr, 1999)
is passed through the disc, it will break down ahead of the
that muscle can translate and it gives you a feel for the raw
facets and vice versa.
strength of these passive structures. And bear in mind that
the muscles are able to absorb forces as much as 33 times
Load sharing bodyweight in sprinting according to Lees (1999).
There are a few considerations that may shed some light
Very simply put, if any one part of the biomechanical chain is on this:
utilized in favor of sharing the load, it will undergo greater First, the nervous system will always migrate the body to
cumulative microtrauma and is most liable to undergo changes its position of strength. When someone has adopted
in tensile strength and eventual degenerative change. a specific posture for a prolonged period of time and in this
A simple example of this is the lumbo-pelvic rhythm, instance (where we are using the example of a flat-backed
where overuse of a lumbar strategy (flexion through the [hypolordotic] sitting posture), the lumbar erectors will
spine in forward bending) will increase risk of lumbar lengthen by laying down sarcomeres in series and/or become
injury, whereas those with a hip strategy (flexion through stronger in their outer-range; which will alter static and
the hip in forward bending) will increase risk of hip injury dynamic lengthetension relationships about the lumbo-
(see Figure 5 below). pelvic region, respectively (Chek, 2001; Sahrmann, 2002).
Similarly, within the spine, if one component is used to The upshot of this may be that the faulty seated posture
bear load alone or take greater load than it is designed to, is transposed into activities of daily living (e.g. lifting,
the result will be greater cumulative microstress and the twisting, squatting, walking) and into sports or other more
potential of subsequent degenerative change to that over- highly loaded activities.
stressed component. If we just pick one of these activities, such as walking,
The concept of cumulative microtrauma, or cumulative and consider how this may affect the lumbar spine of
trauma disorders, or repetitive strain injuries has been someone with a flattened lordosis, it will provide a useful
thoroughly discussed in the literature; including a recent illustration for how structures as strong as discs, ligaments,
JBMT editorial (Wallden, 2009). Such a process of accumu- joint capsules, and so on, become affected by cumulative
lating microscopic stress in the tissues can result in microstress.
a decline in tensile strength (McGill, 2002), which culmi- Gracovetsky (1988, 1997) explains that the ground
nates in greater vulnerability to injury from ever decreasing reaction forces returning through the lower limb after heel-
loads, such as lifting a small child, to weeding a flower bed, strike travel into the lumbar spine creating loading through
to sneezing, to tying a shoe-lace, to sleeping in a draught both the discs and the facets up the length of the spine
(where consequent changes in muscle tone may exert ipsilateral to the heel-strike. For example, a left heel-strike
a compressive load through the spine). will drive ground reaction forces through the left leg into
In practice, it is most commonly these kinds of scenarios the spine on the left hand side compressing the facets on
that are presented by patients as the causative factor in the left side of the spine, and due to the contralateral
their back pain, yet the discerning therapist would coupling of the arms and legs in gait (Van Emmerick et al.,
presumably recognize the highly implausible nature of 1999) there will be a relative left rotation of the lumbar
Neutral spine 353

PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

how this 70 kg load may affect his lumbo-pelvic integrity,
we find that multiplying the steps taken on an average day
(10,000) by his bodyweight (70 kg) which may be
further multiplied by between 1 and 3 times due to the
compressive penalty of the up and down sine-wave motion
of gait, we reach a total of somewhere between
10; 000 ! 70 kgZ700; 000 kg ! 1Z700; 000 kg
.and.
10; 000 ! 70 kgZ700; 000 kg ! 3Z2; 100; 000 kg
Clearly, this is a lot of loading, but let us not forget that this
is only the walking. If we were to take the kind of person
that may be engaging in the activities prescribed by
Liebenson in this section and issue of JBMT, then with each
step they take, as a runner, they will be loading between 3
and 7 times bodyweight through their spine with each step
(Lees, 1999). If this person also plays sports, or lifts chil-
dren, or has a manual job, the loading will be multiplied
dramatically again. Importantly, these are the kinds of
loads that a spine must handle per day. If we want to look
at the same loading across longer periods of time e just
based on the lower figure of 700,000 kg, which is only based
on the walking loads put through the spine, we can see
some startlingly large figures begin to emerge.
700; 000 kg ! 7 daysZ4; 900; 000 kg

700; 000 kg ! 31 daysZ217; 000; 000 kg

700; 000 kg ! 365 daysZ2:5558 kg

Figure 3 On heel-strike, there is a significant ground reac-
tion force which travels up through the lower limb and into the
spine. At each of the viscoelastic structures en route, a certain 700; 000 kg ! 10 yearsZ2:5559 kg
proportion of this energy is captured and stored in the collagen Suddenly, from being impressed at the immense strength of
fibers allowing brief deformation and recoil. Ultimately the the discs, ligaments and other tissues of the body, it
ground reaction force travels up through the spine de-rotating becomes painfully clear why slight aberrations in posture
each segment as it goes and passes into the upper extremity which create greater loading through one of the weight-
where, finally, it is expressed as kinetic energy in the hands. bearing structures (in this scenario, the posterior disc), can
When the movement of the hands meets resistance from the result in dramatic weakening and diminished tensile
elasticity of the supporting musculature and connective tissue, strength leaving the disc exposed to injury from a simple
an elastic recoil begins to swing the arm in the opposite low load activity, like picking up a pencil.
direction, thus counterbalancing the forward swing of the
ipsilateral leg as it enters its swing phase.
Weight bearing in the spine

spine creating torsional stress through the oblique fibers of To revisit Bogduk’s (2005) synopsis of weight bearing
the annulus fibrosis. This loading of the facets and through the spine, we can look at how the assumption that
stretching of the annulus results in a storing of potential weight bearing occurring through the ‘‘tripod mechanism of
energy within the viscoelastic collagen fibers which will the spine’’ proposed by Kapandji (1974) and others, may be
recoil to drive the spine into right rotation and, with it, incorrect. Bogduk (2005) described earlier research in
draw the right leg through its swing phase. This mechanism which load sharing was suggested to fall around a 60:20:20
that allows this is otherwise known as the spinal engine ratio (disc to facet left to facet right) in the tripod mech-
(Gracovetsky, 1988) (Figure 3). anism. However, Bogduk’s conclusion based on the most
The importance of this understanding becomes clear current available evidence was that, in fact, the disc may
when we look at both the loading and the concept of load be the only weight-bearing structure; the facets remaining
sharing in the context of human gait. completely uninvolved.
The average person takes around 10,000 steps per day What ramifications does this have for our flat-backed
(Morris, 1985). This means that the spine undergoes office worker? It would, at first glance, appear to indicate
a compressive load with each heel-strike and toe-off, that he is ‘‘back to square one’’. If the disc is the only
somewhere between 1 and 3 times bodyweight. If we take weight-bearing structure and the disc has ruptured, when
an average 70 kg adult male, who has sat at a desk for many he bent to pick up a pencil, then may be it was simply
years with a flat-backed (hypolordotic) posture and look at ‘‘meant to be’’. perhaps a genetic aberration?
 354 M. Wallden
PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

However, even if the posterior column (the two

zygapophyseal joints) does not take responsibility for axial
loading, then loading through the anterior column (discs Inferior facet (L2)
and vertebral bodies) that is more anterior than the centre Superior facet (L3)
of balance of the disc (i.e. spinal flexion) will always cause L3
posterior migration of the nucleus; thereby creating sus-
tained tensile loading to the weaker postero-lateral aspects L2
of the disc.
Bogduk (2005) explains that the facet joint orientation,
being in the sagittal plane in the lumbar spine, does not Disc
allow for weight bearing through these structures.
However, it is worth noting that the L4e5 and, in particular,
the L5eS1 facets e the levels of the spine which account
for somewhere in the region of 97% of all spinal injuries
(McKenzie, 2003) e are commonly orientated in a position
to allow weight bearing. Additionally, hydrostatic pressures
within the joint may account for some of the loading the
posterior columns can bear without direct weight-bearing L2
contact of the joint surfaces themselves.
Bogduk (2005) goes on to qualify his assertion of 100%
weight bearing through the disc by stating that for the facet
joints to participate in weight bearing, an aberration in
their orientation must occur. A clinical example of just such
an aberration may be the lower crossed syndrome e or, put
another way, a spine that is held in sagittal extension and L3
therefore is out of neutral.
One further consideration is that Bogduk’s discussion is
based on assessment of a static upright spine, however, as
discussed above, Gracovetsky shows, in simple everyday Figure 4 As the superior vertebra (in this case L2) moves into
tasks, such as walking, the spine naturally migrates left rotation on the vertebra below (L3) the viscoelastic
between rotated and laterally flexed positions as well as annular fibers of the disc undergo elastic elongation; storing
axially flexing on the heel-strike (resulting in sagittal energy which will recoil with the next step of gait. Similarly,
extension) and axially extending during mid-stance the right inferior facet of L2 will approximate, compressing the
(resulting in sagittal flexion) (Figure 4). joint cartilage against the joint cartilage of the right superior
In summary, the disc may take 100% of the load under facet of L3. This compression will also recoil with the next step
normal static upright, neutral spine conditions. However, if of gait, providing a highly efficient means of locomoting in
the spine moves into sagittal flexion (a hypolordotic spine), a gravitational field. If speed development is a goal, as in
the loading in the posterior disc will increase and recipro- Liebenson’s accompanying article, then spinal neutral must
cally, if the loading moves into sagittal extension also be a goal.
(a hyperlordotic spine) the loading through the facet joints
will increase.
Hence, the point of balance is where the load on the disc In very much the same way that a similar epidemiolog-
passes directly through the centre of the nucleus pulposus; ical paper produced by Ross et al., in 2007 stated that there
which means, like sitting on a Swiss ball, the hypothetical was no connection between sitting and back pain, a paper
neutral spinal position is rarely achieved, achievable, nor which essentially suggests no connection between posture
maintained in activities of daily living; instead the neutral and back pain feels intuitively wrong.
spine should be viewed as a conceptual axis about which Should one analyse further to see if the intuition is
the spine functions most optimally. correct? Or simply accept that the figures stack up and
therefore accept the epidemiologist’s conclusion?
Of course, the answer is a matter of personal prefer-
Counter arguments to the neutral spine ence. Nevertheless, common sense would seem to suggest
principle that if something doesn’t ‘‘feel’’ right, it may demand
further examination.
There is a current paucity of high-quality research to
provide support for the neutral spine principle. Christensen
and Hartvigsen (2008), for example, performed a system- Negentropic, homeostatic mechanisms and
atic critical review of published papers detailing associa- adaptive capacity
tions between spinal curves and health.
The findings of the review were that evidence from Living systems exhibit a negentropic capacity to maintain
epidemiological studies does not support an association some level of homeostatic balance. When there is a stressor
between sagittal spinal curves and health, including spinal to that system, depending on the intensity and volume of
pain. stress, the system will seek adaptive measures to allow
Neutral spine 355

PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

continued function without its own breakdown or demise the neutral spine principle. Fourteen percent might be
(Sole and Goodwin, 2000). expected to have more optimal loading through the spine,
A healthy or stable system typically has greater adaptive while 3.5% would be expected to have greater compressive
capacity than a system that has been under high volumes of loading through the posterior elements, the facet joints.
stress (cumulative or otherwise), or that experiences These clinical findings, then, would correlate well with
a sudden high intensity of stress (Wallden, 2008). the finding by Boos et al. (1995) that somewhere between
The SAID Principle (specific adaptation to imposed 76% and 96% of people have posterior disc bulges when
demands) suggests that a living system will adapt to the assessed using MRI.
specific demands imposed upon it. For example, someone In fact, Boos et al. (1995) found that not only was there
who trains in the gym, or who runs long distances, will note a 96% percent level of disc bulge in those who had symp-
adaptations in their body that are specific to the demands toms of disc injury, but that those without any history or
they are imposing upon it (Baechle and Earle, 2000). back pain and who were totally asymptomatic had a 76%
However, if the expected adaptations are not forth- incidence of posterior disc bulge on MRI scan too.
coming, or if injury and pain occur as a result, then the This is a classic example where a lack of insight may
system has reached its adaptive limit and is now ‘‘malad- result in ‘normal’ being mistaken for ‘functional’ or even
apting’’ or has reached the exhaustion phase in Selye’s for ‘optimal’. The norm is that at least three quarters of
stressor model (Selye, 1978). people (even without any history of back pain) will have
This same mechanism occurs in the spine when it is kept a disc bulge when scanned, yet is this functional? Clearly
too flexed (as in our example above) or too extended, for not. It may be a ‘functional compensation’, but it is not
too long. Initially there will be adaptation to help the nearly as functional as a healthy intact disc; which would
system to cope with prolonged sitting postures, for be optimal.
example, but ultimately that adaptation may reach a point In a similar way, it is ‘normal’ for people to have flat
when the capacity to further adapt has been exhausted and backs, but this does not make it functional (other than as
the structures under load (the posterior annulus and a compensation), and certainly does not make it optimal e
posterior ligamentous system in this instance) will collapse. especially in view of the loads the spine must bear
(described above).
When assessing the spinal function of people from
Determining a patient’s level of adaptive industrialized nations, then, the progression will tend to
capacity look like this:

With this understanding, as a consulting therapist or Dysfunctional/Functional with compensation/

movement specialist, it would next be most useful to have Functional without compensation/Optimal
a knowledge of where our patients’ systems are at in terms
of adaptive capacity.
The norm (or the modal distribution) will fall toward the
With respect to the neutral spine principle, a simple,
left hand side of the progression. Our objective as move-
non-invasive, means of assessing the spinal position is to
ment therapists is surely to not only treat dysfunction, or to
use inclinometry (Ng et al., 2001; Saur et al., 1996). When
assist with compensation e nor even just to return patients
we measure spinal curvature, we can gain an insight into
to optimal, but to prevent them from slipping toward the
how the patient habitually adopts their own unique
left; avoiding dysfunction and optimizing function without
‘‘neutral position’’ and what this may mean in terms of
compromise.
loading to different structures in and around the spine.
This, then, allows us a general view as to what the current
spinal curvature is versus the optimal spinal curvature. Conditioning in the neutral spine
According to Chek (2001) and Schafer (1987), the
optimal spinal curvatures have been mathematically Many of the leading rehabilitation specialists utilize the
calculated to fall between 30" and 35" for the lumbar neutral spine principle in their rehabilitation protocols. Lee
lordosis, the same for the thoracic kyphosis and the same (2004), for example, states that attempting to teach exer-
for the cervical lordosis. Other references, suggest that the cises that isolate the local muscles, such as transversus
figures may be different, but this may be due to differing abdominis or deep multifidus, without first teaching the
measurement techniques, and looking for normality rather patient to maintain a neutral spinal position can lead to
than for functionality or for ‘‘optimum’’. frustration and disappointment for the therapist and patient.
For example, clinically it is common to find that the One reason for this is that the spinal posture in which the
lumbar curve is flattened. A brief analysis of patients to transversus activity is greatest is the neutral spinal position
recently attend our clinic (n Z 28) shows that 82% of them (Richardson et al., 1999, 2004; Lee, 2004). Other reasons
had a lumbar curve that was flatter than the reference include those discussed above with respect to load sharing.
range (<30" ), 14% of them were within the reference range Comerford and Mottram (2001) also favor use of neutral
(30" e35" ) and only 3.5% were above the reference range spinal position in their motor control re-education, as does
(>35" ). McGill (2002, 2007) stating ‘‘it appears that the safest and
In this instance we would expect that 82% would have mechanically justifiable approach to enhancing lumbar
increased loading into the anterior pillar of the spine (the stability through exercise entails a philosophical
discs) and would therefore be more prone to posterior disc approach. that ensures a neutral spine posture when
bulge or to other posterior myoligamentous strain, based on under load.’’ (McGill, 2007).
 356 M. Wallden
PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

Chek (2001) also utilizes a neutral spine principle in his However, if strength is built in the neutral spine posi-
rehabilitation programs and, importantly, discusses the tion, then lengthetension relationships are optimized
relevance of this to motor learning when performing more through the trunk because the muscles about the trunk
functional movement patterns and those which place the become strongest in their mid-range as opposed to their
spine under higher loading, which may be e-concentric, inner-range on one side of the spine and their outer-range
ballistic, perturbatory or plyometric in nature. on the other side of the spine. The end result of optimal
On this same note, McGill (2007) suggests that whereas lengthetension relationships in the spine includes greater
steady-state motor patterns are important for daily capacity to generate force, lower levels of shear forces and
activity, the health of reflexive motor patterns is critical for optimization of lengthetension relationships at proximal
maintaining stability during sudden events. appendicular joints; which will almost invariably be passed
on through the limb to the periphery. In the neutral spine
posture transversus abdominis activation is optimized and,
Making a mummified meal of things importantly, outer unit dominance patterns, such as rectus
abdominis dominance, hamstring dominance, upper
One objective of the neutral spine principle, which is trapezius dominance and external oblique dominance are
oft-overlooked is to provide a platform from which, or as all-but nullified.
suggested above an ‘‘axis around which’’, movement can As Richardson et al. (2004) state, when the spinal curves
effectively occur. are maintained, this is the most energy efficient position
Too frequently, the mix of training neutral spine philoso- for the body to stay upright against forces of gravity and
phies at back school, to those who are highly suggestible due other extrinsic forces it may encounter.
to pain behavior, results in a virtual mummification of the But back to the question of strength training in this neutral
spine and a robotic appearance to movements. spine position, how can it be of benefit? Sahrmann (2002)
In the long term, this is neither helpful, nor functional e shows that when there is a laying down of sarcomeres in
especially where a return to sports or to activities of daily parallel and/or a hypertrophy of muscle fibers due to training
living is sought. A spine held in its neutral position by effects, so the number and size of series elastic components
overactive local and global muscles will result in increased also increase. Series elastic components act much like
compressive loads, increased waste metabolite production, a coiled spring; hence, the more of them there are, and the
decreased venous and lymphatic drainage and an entire bigger the spring, the more resistance that muscle has to
cascade of events following from there including compro- stretch. The implications of this are discussed below.
mised repair and trigger point development to name a few. A further benefit of hypertrophy training is that when
there is an increase in muscle fibre size and/or number
(hyperplasia) the hydraulic amplifier mechanism of the
Strengthening your position spine is enhanced; meaning that the intracompartmental
pressures with the posterior compartment of the thor-
Nevertheless, the neutral spine principle is more than just acolumbar fascia will be increased creating an increased
teaching the patient ‘‘where’’ a neutral position is, it is rigidity to the spine; minimizing risk of being caught ‘‘off
about training the patient to be strong in the neutral spinal guard’’. We would do well to remember also that some of
position. This is important as the body will always migrate the original research into the role of multifidus in low back
toward its position of strength. pain demonstrated that within 24 hours of the onset of
Being strong in the neutral spinal position requires pain, the cross-sectional diameter of the lumbar multifidus
training and not just holding a position against gravity, but had dropped to 69% (#8%) of its original diameter
holding a position against external loads, such as dumb- (Richardson et al., 2004). This dramatic change cannot be
bells, barbells, kettlebells, medicine balls, cables or any attributed to atrophy, but only to inhibition of the muscle,
other kinds of effective resistance training device. reducing resting tone and hence resting cross-sectional
Why is this so? First and foremost, to create an adaptive area. This just highlights the importance and relevance of
response in the strength fibers of any given muscle requires good resting tone and the hydrostatic function even of
a certain intensity of load. In strength conditioning, it is ‘‘resting’’ muscle in spinal stability.
now well documented that moving a load that one can take What this means is that by inducing a hypertrophy
through the desired range of motion between 8 and 12 response we have the benefits of increased strength when
times before fatigue (what would be termed an ‘‘8e12 rep called upon, increased resting cross-sectional diameter
max’’ load) will optimize strength gains and hypertrophy enhancing the hydraulic amplifier mechanism, increased
responses within the muscle (Chek, 1996; Poliquin, 2006; size and/or number of series elastic components resisting
Baechle and Earle, 2000). stretch and, hence, we have built for ourselves a significant
The question is, do we want strength gains in the muscle, contribution to the ‘‘passive’’ stability of the lumbar spine,
or just better control? McGill (2007) suggests that having by working with the ‘‘active’’ component of the joint
a stronger back has no prophylactic value. However, the stability subsystem.
reference cited in this instance only assessed back strength So, much the same as when McGill (2007) suggests: the
as a potential contributing back pain variable, irrespective of health of reflexive motor patterns is critical for main-
the position of strength. If someone is immensely strong, but taining stability during sudden events, perhaps even more
in a flat (hypolordotic) spinal position, they are at just as significantly, the passive subsystem offers protection and
much, if not more, risk of disc injury as the next person who biofeedback sooner than the active subsystem can reflex-
has a weak and flat lumbar spine. ively activate. As we’ve discussed above, when the active
Neutral spine 357

PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

i gs
trn

ngs
Hams

A Normal lumbar and B Hamstri

Limited hip flexion with C Limited lumbar flexion
hip flexion excessive lumbar flexion with excessive hip flexion

Figure 5 During functional activities, such as gait, there are stretcheshortening cycles through the annulus of the disc and facet
joint capsules, and compressionerecoil cycles through the cartilage on the facet joint surfaces. Increased loading anteriorly or
posteriorly may have profound consequences across a period of time.

system is in a functionally hypertrophied state, it will kinds of loads that Olympic lifters lift. Hence, to get these
contribute significantly to this protective passive subsystem heavy loads off the ground the most refined and elite lifters
effect; something that can be achieved relatively rapidly, in the world utilize the legs and allow their lumbar spines
especially in comparison to the 300e500 days to heal and to go into kyphosis in order that the thoracolumbar fascia is
adapt often quoted for the connective tissue or the passive an effective force transducer from legs to trunk. If the
subsystem classically described Chek (2001). spine is left in neutral, then the thoracolumbar fascia
remains on slack, the force from the legs cannot be
effectively transferred into the trunk and the lift is inef-
Load sharing and load transfer fective at best, dangerous at worst. This sounds like
a water-tight case.
So, we have discussed load sharing between facets and However, one problem with taking this view is that just
discs, or between connective tissues and muscles, and to because the elite lifters do this, does not mean it’s the
a degree how that load may be transferred up through the safest way to lift for the rest of the population. Since only
tripod mechanism of the spine, however we haven’t a fraction of people ever make it to an Olympic games for
discussed how this might be applied to lifting. the sport of Olympic lifting, they are not likely to be
There is much controversy over how to effectively and representative of the general population who do not reach
safely lift an object; and this may be for the reason that the that level of sporting attainment. Additionally, the likeli-
way to effectively lift an object may, in fact, be completely hood is that anyone who makes an Olympic games has
the opposite of how to safely lift it! a very functional spine; perhaps even an optimal spine. For
Gracovetsky (1988), for example, has demonstrated every person to reach this level of achievement there will
conclusively that the most effective way to lift a heavy be many more who ended up in casualty or on the surgeon’s
object is to use a flexed lumbar position, while the likes of table with ruptured lumbar discs.
McGill (2002, 2007) and Chek (2001) recommend maintain- What we first must ask is ‘‘how many of the people we
ing a neutral spinal position in lifting. Why is there such work with are likely to have a posterior disc bulge?’’ The
a discrepancy? And who is correct? answer, of course, is somewhere between 76% and 96%
Probably the truth is that both are correct and here’s why: according to Boos et al. (1995). Therefore, is it preferable
Gracovetsky’s argument is that in order to even lift the loads to teach an ‘‘effective’’ lifting style (with lumbar flexion
that they do, Olympic lifters must utilize both the leg muscles which will likely rupture the disc) or a ‘‘safe’’ lifting style
and the lumbar erectors to get the load off the ground. (maintaining neutral) which will minimize anterior loading
Gracovetsky (1988) calculated that the lumbar erectors of the disc and therefore posterior migration of the
themselves do not have the strength to be able to lift the nucleus? The answer, I hope, is obvious.
 358 M. Wallden
PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

Table 1
Finding Corrective mobilization Corrective stretch Corrective exercises
Thoracic curve Foam roller longitudinal/ Swiss ball Prone cobra
increased general transverse rectus abdominis stretch
Thoracic curve e Prone Swiss Crunch, breathing squat
decreased general ball hang stretch
Lumbar curve Foam roller Knee-hug stretch Lower abdominals,
increased in general longitudinal with forward ball
hip flexion roll,
supine hip extension
Lumbar curve Foam roller Swiss ball Prone jack-knife,
decreased in general longitudinal with rectus abdominis stretch alternating superman,
noodle prone
(placed deep to umbilicus), trunk and hip extension
McKenzie extension push-up
Inclinometry angle Foam roller Rectus abdominis Breathing prone
increased at CT (kyphotic) longitudinal/transverse, Lewit stretch of Swiss ball cobra, The fish,
CT mobilization Prone cobra
decompression,
front squat
Inclinometry angle e Prone Swiss Crunch, Horse
decrease at CT (flat) ball hang stretch stance dynamic
Inclinometry angle Foam roller Preacher stretch, Prone cobra,
decreased at TL (flat) longitudinal with McKenzie extension prone trunk
noodle push-up extension
(placed toward TL) (with towel taut over TL) (Roman chair/Swiss ball)
Inclinometry angle e Oblique abdominal Oblique crunch,
increased at TL (kypho- stretch over breathing squat,
lordotic) Swiss Forward
ball, Iliopsoas ball roll,
stretch, knee-hug any exercise
stretch (pelvis off ground) with neutral spine
Inclinometry angle Foam roller McKenzie extension Prone hip extension,
decreased at LS (flat) longitudinal with push-up prone pelvic tilt
noodle (with towel taut over LS)
(placed toward LS)
Lumbar curve e Knee-hug stretch Prone jack-knife,
increased at LS (lordotic) pelvis on ground lower abdominal
series (dead-bug)
Note: All of the exercises described above will help to move the spine in the correct direction, based on the neutral spine principle, but
any exercise done in a neutral spine position will do the same.

To supplement further, the question over whether or not middle layer of the thoracolumbar fascia) to stabilize the
to progress the neutral spine technique beyond the reha- lumbo-pelvic region.
bilitation setting and into performance conditioning is However, this again, depends on how confident the
another hotly debated topic. trainer, coach or therapist is that the patient falls in the
Again, Gracovetsky’s (1988) description seems conclu- 4e24% of people who do not have a pre-existing disc
sive; especially when one considers that it is at around 45" bulge. In addition, the experienced strength and condi-
of trunk flexion or 90% of lumbar flexion e just as the tioning coach will be aware that muscles are around 1.2
posterior ligamentous system is beginning to undergo times stronger during an eccentric contraction than in
significant stretch stimulation, that the lumbar erectors are a concentric contraction. Taking into account both safety
reflexively inhibited by the nervous system to minimize and effectiveness, it would seem then to make sense, at
compressive penalty through the spine and the body the very least to start the lift from a neutral spinal posi-
switches to the hip extensor mechanism (and the liga- tion; ensuring a centralized nucleus at the beginning of
mentous tension generated by the hamstrings, through the the lift. As the lifter engages the weight and begins to lift
sacrotuberous ligament into the deep lamina of the it, it may indeed be that the load is too much for the
posterior layer of the thoracolumbar fascia and gluteus lumbar erectors to overcome (as calculated by Gracovet-
maximus, via the superficial lamina of the posterior layer of sky, 1988), however, if those lumbar erectors are already
the thoracolumbar fascia) in conjunction with the hoop engaged in an isometric contraction and in a neutral spinal
tension generated by the transversus abdominis (via the position, they will contract eccentrically as the spine
Neutral spine 359

PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

Figure 6 Foam roller longitudinal with lumbar noodle. Use of
a longitudinal foam roller aids in creating creep to the anterior
longitudinal ligament for those with increased thoracic
Figure 8 Swiss ball rectus abdominis. This is an important
kyphosis and the posterior ligamentous system for those with
stretch for most people as the rectus is so commonly dominant
increased lumbar lordosis. The addition of a 2-inch noodle,
in back pain populations and in those with upper crossed
deep to the umbilicus, is useful for those with a flattened
syndromes. A tight rectus abdominis will increase the first rib
lordosis to create creep in the anterior longitudinal ligament in
angle and the flexion at the CT junction.
the lumbar spine.
important to have tools to both measure the patient’s start
is drawn into flexion; the strongest way they’re able point, and to measure the efficacy of any interventions made.
to work. For the pain patient, utilization of pain scales may be
Ultimately, this second version of lifting technique one measure that is of practical use to screen for progress.
would seem to realize both the requirements for minimizing However, as Liebenson (1999) points out, it may not be
unnecessary stresses through the disc, while activating the useful in the longer term to focus the patient on their pain
lumbar erectors in their most effective contractile state, e even if this is what they would like to focus on in the first
and utilizing the thoracolumbar fascia mechanism by instance. Additionally, of course, patients who we work
default if required (Figure 5). with that are not in pain, or perhaps do not have back pain
One further lifting consideration which is important to will need a different way of measuring progress.
ascertain is the lift duration. As Gracovetsky (2008) Instead, a focus on moving the individual toward optimal
explains, the collagen found in the connective tissues of the function is of great psychological and motivational benefit.
spine will undergo an initial creep effect in around This strategy can then be applied to groups who are in pain
0.33 seconds. Therefore if the lift is an explosive Olympic and those who are looking to optimize performance, or
lift, the connective tissues may be effective in stabilizing both.
the spine for its duration. However, if the lift is carried out
at a slower tempo, or repetitively (as is often the case in
strength and conditioning programs), taking a neutral spine
strategy makes a lot more sense.

Therapeutic considerations

If the neutral spine principle is to be adopted in practice,

despite some evidence questioning its value, then it is

Figure 9 Forward ball roll. This exercise, reviewed in the

paper presented in this section [Duncan M. (2009) Muscle
activity of the upper and lower rectus abdominis during
exercises performed on and off the Swiss ball], is ideal for
Figure 7 Prone cobra. The prone cobra is useful for activating the abdominal wall, with a bias toward the upper
increasing load on the thoracolumbar extensors specifically, abdominals. If a neutral spine is maintained it will aid
and the scapula retractors. correcting any muscle imbalance about the pelvis.
 360 M. Wallden
PREVENTION & REHABILITATIONdEDITORS: WARRICK MCNEILL AND MATT WALLDEN

a rehabilitation or conditioning program to enhance moti-

vation and to ensure effective interventions that have been
deployed e and, indeed, that they haven’t been ‘‘too’’
effective and over-corrected the imbalance originally
measured.

Conclusion

Though there may still be an excess of philosophy and

paucity of high-quality research surrounding the neutral
spine principle in its relation to gait, to lifting and to other
activities of daily living, clinical experience suggests that it
is a very useful clinical management tool.
Despite the fact that much of spinal gravitational
loading will go through the disc, it is clear from simply
observing the trabecular formation of the facets that they
are designed to take some significant loads; which can only
be increased in relative extension and decreased in relative
flexion of the spine (Figure 10).
While Christensen and Hartvigsen’s (2008) study strug-
gled to find a correlation between sagittal spinal curves and
spinal health, it did not and could not control for all of the
Figure 10 Since the trabeculae are known to form along the
other factors which may determine whether or not an
lines of stress, they reveal the function of the tissues and
aberrant spinal posture may result in pain; from nutritional
identify the facets as load-bearing structures; whether this
status, to hydration levels, to immune status, to adrenal
load is axial, rotary or a combination of multiple vectors. An
function, to blood sugar regulation, to gut permeability, to
extended spine will always increase loading in the facet joints.
sleepewake cycles, and so on and so on; all factors that
Spinal inclinometry may either impair rate or optimize it.
Those who have a poor capacity to heal, for whatever
reasons, are those most likely to breakdown when sagittal
Spinal inclinometry is probably the most accessible and
curves are disrupted, while those who have a good capacity
non-invasive method of assessing spinal posture, and it
to heal (or to compensate) are most likely to survive an
offers clinically useful gauge in terms of intra-rater reli-
aberrant posture. Nevertheless, any aberration in posture,
ability (Saur et al., 1996; Ng et al., 2001).
or in motor control will ultimately result in greater accu-
Based on the figures discussed above, we would be
mulation of stress in the system than an optimal posture.
looking to measure angle of inclination at the lumbo-sacral
If we can assume that optimal posture is both measur-
junction, the thoracolumbar junction and the cervico-
able and achievable, then the only question remaining is
thoracic junction. (Measurement with inclinometers is of
‘‘Is it desirable?’’
little value at the occipital-atlantal joint, so is not usually
That is a personal question, and one which only you and
performed at this level.)
your patient can answer together.
To calculate the total lumbar curve, the scores from the
lumbo-sacral junction and the thoracolumbar junction
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