Spinal stability is a cornerstone of musculoskeletal health and functional movement. For DCs, understanding and promoting spinal stability is essential for everything from managing various conditions, such as low back pain, to athletic performance enhancement.
This article delves into the anatomy and biomechanics of spinal stability, explores the clinical significance of instability and outlines evidence-based strategies for assessment, treatment and rehabilitation.
The ability of the spine to maintain its structural integrity and control during movement and loading is best termed “spinal stability.” As DCs, we fully understand the benefits of spinal stability and the ramifications of poor spinal stability. A stable spine is critical for preventing injuries, optimizing functional performance and alleviating chronic pain. DCs play a pivotal role in assessing and enhancing spinal stability through manual therapies, corrective exercises and patient education.
Modern approaches to spinal stability focus on the interplay between the passive (bony and ligamentous structures), active (muscular system) and neural subsystems. Dysfunctions in any of these components can compromise stability, leading to compensatory patterns, pain and a heightened risk of injury.
Anatomy and biomechanics of spinal stability
Stabilizing subsystems
Passive subsystem
Comprises vertebrae, intervertebral discs, ligaments and joint capsules.
Provides structural support and acts as a passive restraint against excessive movement.
Active subsystem
Includes local stabilizers (e.g., multifidus, transverse abdominis) and global movers (e.g., erector spinae, rectus abdominis).
Local stabilizers offer segmental stability, while global movers control gross spinal movements.
Neural control subsystem
Integrates proprioceptive input and coordinates the activity of stabilizing muscles.
Dysfunction in proprioception or motor control can lead to instability and compensatory patterns.
Definition and clinical significance
Spinal instability occurs when the stabilizing systems fail to maintain normal alignment and control under physiological loads. This condition can result from:
Degenerative changes (e.g., spondylolisthesis, disc degeneration)
Trauma (e.g., fractures, ligament tears)
Neuromuscular dysfunction (e.g., motor control deficits)
Foundational discrepancies (e.g., hyperpronation, ankle and foot dysfunction, leg length inequality, abnormal hip versions
Symptoms and functional impairments
Patients with spinal instability may present with:
Chronic low back pain or recurrent episodes of acute pain
Reduced range of motion
Muscle guarding or spasms
Perceived weakness or “giving way” of the spine
Early-onset osteoarthritis or recurrent lower extremity injury
Gait abnormalities, leg length discrepancies, ankle or foot pathology
Assessment
Subjective
Patient history: Identify patterns of pain, functional limitations and aggravating factors.
Red flags: Exclude serious pathologies such as fractures, infections or malignancies.
Physical examination
Postural analysis
Observe alignment and asymmetries in standing, sitting and dynamic positions.
Range-of-motion tests
Assess flexibility and end-range stability.
Special tests
Prone Instability Test: Identify lumbar instability.
Beighton Score: Screen for generalized ligamentous laxity.
Functional movement screening
Analyze movement patterns such as squats, lunges and gait for compensatory strategies.
Foot scans
Because foot posture is strongly linked to low back pain, faulty gait patterns and chronic repetitive injury, scan the feet with a laser scanner, evaluating foot intrinsic muscles, assessing gait and conducting static postural analysis.
Imaging and diagnostic tools
X-rays and MRIs can reveal structural abnormalities but should be used with clinical findings.
Strategies for enhancing spinal stability
Chiropractic adjustments
Spinal adjustments restore joint mobility, reduce pain and optimize neural communication. Key benefits include:
Improved proprioceptive feedback
Reduced muscle guarding
Restored segmental alignment
Core stabilization exercises
Targeted exercises improve the function of stabilizing muscles and promote neuromuscular control. Effective approaches include:
Local stabilization training
Focus on deep core muscles (e.g., transverse abdominis, multifidus).
Example: Abdominal drawing-in maneuver, transverse abdominis activation with breath control, erector spinae activation with appropriate muscle sequencing patterns.,
Global stabilization training
Strengthen superficial muscles for dynamic stability.
Example: Planks, bird-dog exercises. Progressions are key to success.
Neuromuscular reeducation
Improving proprioception and motor control is essential for long-term spinal stability. Techniques include:
Balance training using unstable surfaces (e.g., Bosu ball). Sensorimotor integration (proprioception) exercises are imperative for all successful rehab programs that aim to stabilize the spine.
Dynamic movements emphasizing controlled spinal alignment. (Check breath control with activity and progressions of dynamic movements such as squats, bending or sport-specific movements.)
Soft tissue therapies
Manual therapies, such as myofascial release and trigger-point therapy, reduce muscle tension and address myofascial dysfunction contributing to instability. Chronically hypertonic muscles may be firing prematurely or at times inappropriate to ensuring the spine’s stability. Releasing muscles oftentimes allows for a reset of this faulty pattern.
Postural retraining
Teaching patients to maintain proper alignment during static and dynamic activities is vital for reducing mechanical stress on the spine. Mirror training or wall alignment training offers excellent visual and or kinesthetic feedback on faulty vs. proper alignment with movement.
Ergonomic modifications
Educating patients on workplace ergonomics and proper lifting techniques can mitigate external stressors. The key is reducing the opportunity for repetitive stress/injury. For athletes, reviewing techniques that may be faulty or causing continued injury opens a door for healing recurring injury.
When modifying ergonomics, patients should also consider a custom flexible orthotic. In faulty foot posture, the pelvis has great difficulty attaining stability. Therefore, placing a custom flexible orthotic will assist in correcting the ergonomics of posture and movement. This is an excellent opportunity to set the kinetic chain up for success early in care.
Lifestyle modifications
Weight management
Excess body weight increases mechanical load on the spine, exacerbating instability. We know that up to 25% of patients who suffer from a low back pain episode become chronic low back pain patients. Recent research by Nieminen, et al., reviewed 111 articles to identify the most common risk factors for chronic low back pain. This research demonstrated that higher pain intensity, higher body weight, carrying heavy loads at work, difficulty in work positions and depression were the most frequently observed risk factors for chronic low back pain.
Physical activity
Regular, low-impact activities such as swimming, walking or yoga promote overall spinal health. Extensive research supports exercise’s key and pivotal role in low back pain, health and weight management.
Stress reduction
Chronic stress contributes to muscle tension, maladaptive movement patterns and inflammation. Incorporating relaxation techniques such as mindfulness or diaphragmatic breathing can support spinal stability.
Integrate spinal stability into chiropractic practice
Patient education
Empowering patients with knowledge about spinal health and self-management strategies enhances compliance and outcomes. An educated patient is more likely to recover. This is a well-researched phenomenon that has been reevaluated more recently with the introduction of AI-generated healthcare.
Individualize patients’ care plans
Tailoring treatment plans based on patient-specific factors such as age, activity level and instability severity helps ensure optimal results. Personalize healthcare based on how your patient needs to use their body daily.
Final thoughts
Attaining spinal stability is a multifaceted endeavor that requires a thorough understanding of biomechanics, patient-specific assessment and evidence-based interventions. As experts in musculoskeletal health, DCs are uniquely positioned to address spinal instability through manual therapies, exercise prescription and the implementation of extrinsic assistance, such as custom flexible orthotics and patient education. By adopting a holistic approach to spinal stability, DCs can improve patient outcomes, reduce pain recurrence rates and enhance functional performance.
CHRISTINE FOSS, DC, is the director and lead instructor of the Certified Chiropractic Sports Physician program for Northeast College of Health Sciences and director of education for the International Federation of Sports Chiropractic. She was named the 2020 American Chiropractic Association Sports Council Chiropractor of the Year and the 2023 International Federation of Sports Chiropractic Educator of the Year. Foss is also director of education and research for Foot Levelers. She can be contacted at drcfoss@gmail.com or @drchristinefoss on Instagram.
