The Slowly Collapsing Spine
- Gary Moller
- 11 minutes ago
- 17 min read
Adult spinal deformity, osteoporosis and what we can do to remain upright as we grow older
About this series
This article is part of my series about osteoporosis, bone strength and healthy ageing. Rather than concentrating solely on bone-density numbers, I am looking at the whole person: nutrition, muscle, collagen, mineral balance, exercise, posture, balance and the practical things we can do to remain strong, upright and independent throughout life.
There is much more to this subject than can responsibly be squeezed into one article. In this series of articles I explain how living bone is continually broken down and rebuilt, the role of nutrition in supplying the materials for that rebuilding, and the benefits and potential problems associated with medications that interfere with normal bone remodelling. Please bear with me as I work through these subjects. They deserve proper explanation rather than a few hurried bullet points.
Before going further, please read my first article in this series, then come back to this article.
The human body is wonderfully adaptable, but it adapts to what we repeatedly ask of it, whether that adaptation is desirable or not.
I could feel my spine collapsing
Over the years, I have gradually developed a more stooped posture. I suppose I should hardly be surprised. I have spent countless thousands of hours sitting at a desk tapping away at a computer keyboard, usually with my head creeping forwards as I stare into a screen. Add to this many more thousands of hours hunched over the handlebars of a bicycle and I have created an almost irresistible combination of forces encouraging my head and shoulders forwards and my thoracic spine into an increasingly rounded posture.
I have been aware of this tendency for years and have steadily done exercises intended to counter it. Obviously, I have not done enough. Exercise is only part of the answer because there is also the matter of awareness. Even the glasses we choose when working on a computer or reading can make a difference. If we exercise for half an hour and then spend the remaining waking hours gradually folding ourselves forwards, we should not be surprised when the dominant posture eventually wins. The human body is wonderfully adaptable, but it adapts to what we repeatedly ask of it, whether that adaptation is desirable or not.
Then came my cycling accident in Chile on 4 March this year. I fell from considerable height and at speed, landing heavily on my head and upper body and sustaining severe trauma through my cervical and thoracic spine. I narrowly avoided being paralysed. During the weeks that followed, I became aware of something I had never experienced quite so strongly before. Internally, it felt as though my thoracic spine was collapsing forwards.
I found that sensation quite disturbing, if not horrifying. I could feel myself wanting to fold forwards and, for a while, it seemed there was remarkably little I could do about it. My spine and the surrounding tissues had suffered substantial trauma and my normal capacity to hold myself upright had been badly compromised. Rather than trying to overpower the injury, I had to give my body time to settle and heal while carefully introducing movement and strengthening as it became capable of tolerating more.
From the outset, I gave myself a long timetable for recovery. My rehabilitation programme is planned to continue at least through to the end of this year, and in reality I expect some aspects of recovery and adaptation to continue considerably longer - for life, in fact. I have deliberately resisted the temptation to rush things. After fifty years working in rehabilitation, I know that different tissues heal and strengthen according to very different timetables, and trying to force the pace can be an excellent way of turning a recoverable injury into a chronic one.
I am now at the encouraging stage where I can sit comfortably on a bicycle again and look forwards without excessive pain or fatigue developing through my thoracic and cervical spine. That may sound like a modest achievement, but following the trauma I sustained it represents considerable progress. I can feel the supporting muscles becoming stronger, my posture improving and my tolerance for sustained positions gradually returning. There is still plenty of work ahead, and I am in no hurry. I intend to be better off than where I was at before the accident in March. But that is setting an ambitious goal, and it will take time.
Muscle is relatively responsive. With appropriate resistance exercise and adequate nutrition, improvements in muscular strength can begin within weeks, initially through neurological adaptation and then increasingly through changes in the muscle itself. Tendons and ligaments generally demand considerably more patience. Their adaptation is better thought of in terms of months rather than weeks, particularly following substantial injury.
Bone operates on another timetable again. Bone is constantly remodelling, with osteoclasts removing old or damaged bone and osteoblasts laying down new bone. (I'll explain more about bone remodeling in a future article). An individual remodelling cycle occurs over months, but the larger process of restoring, reorganising and strengthening the skeleton following injury or altered mechanical loading can continue for years. That is one reason I have approached my own rehabilitation with patience. I cannot reasonably expect a spine that has been subjected to decades of cycling and desk work, followed by a major traumatic event, to reorganise itself according to my preferred deadline.
There is an important qualification to all of this. Healing and adaptation require raw materials. We cannot expect muscle to strengthen, collagen to be renewed, ligaments and tendons to repair, and bone to remodel successfully if the body is chronically short of the nutrients required to do the construction. This is why I place such importance on a nutrient-dense diet containing adequate complete protein and collagen-rich foods, together with the minerals, vitamins, fats and other nutrients required for healthy lean tissue and bone. My super smoothie includes added collagen and other so-called super nutrients, and when paired with a wholesome natural whole foods diet, it nearly provides what is necessary to develop strong, healthy, lean tissue, including bone. (I'll have an article soon, in this series, with specific nutritional recommendations).
Exercise provides the stimulus. Nutrition supplies the materials. Rest provides the opportunity for adaptation. All three must work together, consistently and patiently.
My experience has also made me much more conscious of something happening all around us. Watch people as they grow older and you will often see a similar process occurring, although usually much more slowly than what I experienced following my accident. The head begins moving forwards. The shoulders round. The upper back becomes increasingly curved. The person loses height and gradually finds herself looking more towards the ground than towards the horizon. Eventually, what began as a subtle postural change can become a substantial physical deformity.
There is an important distinction between saying something becomes common with age and saying that it is inevitable.
We commonly call this a stooped or hunched back. The medical terminology includes kyphosis, and when these changes become substantial they may form part of what is described as adult spinal deformity, or ASD. It can involve excessive forward curvature of the spine, sideways curvature known as scoliosis, or a combination of the two. Osteoporosis and vertebral compression fractures can contribute, but so can deterioration of the intervertebral discs, declining muscle strength, reduced hip mobility and the accumulated effects of how we have used our bodies over many decades.
There is an important distinction between saying something becomes common with age and saying that it is inevitable.
Japan is showing us what is coming
Japan is particularly interesting because it is already confronting on a massive scale something that New Zealand and most other developed countries must increasingly deal with: an ageing population. Japan is at the leading edge of what is sometimes described as a demographic tsunami. That has created an enormous incentive to work out how to keep older people not merely alive, but upright, mobile, capable and independent.
This changes the emphasis of geriatric medicine. Keeping somebody alive is one achievement. Keeping that same person sufficiently strong to get out of a chair, walk to the shops, prepare a meal, climb stairs and continue participating in family and community life is another.
That is why I paid particular attention to an excellent programme from NHK WORLD-JAPAN's Medical Frontiers series called Straightening a Bent Spine Through Exercise. It follows Japanese doctors and physiotherapists working with older people suffering from adult spinal deformity. I strongly recommend watching it because seeing the people before and after treatment conveys something that words and statistics cannot quite capture.
Professor Shirado Osamu, who according to the programme has treated more than 10,000 people with adult spinal deformity, identifies declining muscle function and strength as one of the major contributors. The back and abdominal muscles, together with muscles connecting the pelvis and legs, work together to support the spine. As these muscles lose size, strength and endurance, maintaining the architecture of the spine becomes progressively more difficult. The programme also identifies deterioration of the intervertebral discs and vertebral compression fractures associated with osteoporosis as important contributors.
Weakness encourages stooping. Stooping increases fatigue. Fatigue reduces movement. Reduced movement creates still more weakness.
This fits perfectly with one of the central messages of my osteoporosis series:
We cannot separate the bone from the person carrying it.
When a bent back becomes much more than posture
The Japanese programme follows 77-year-old Baba Asako, whose back had begun curving about two and a half years earlier. Initially she noticed little, but eventually she developed severe pain. At its worst she could neither walk nor stand comfortably, and even going to the bathroom became an ordeal. Her X-ray showed severe forward curvature of the spine.
This is not merely cosmetic. As spinal deformity becomes severe, the programme explains that it can reduce the space available to the lungs and compromise breathing, while also affecting the stomach and intestines. Something that may begin as a gradually rounding back can eventually become a whole-body problem.
Osteoporosis enters this story because weakened vertebral bodies may partially collapse under load, producing compression fractures. One damaged vertebra may not produce the classic rounded elderly posture, but repeated compression and wedging can contribute to progressive loss of height and increasing kyphosis. Meanwhile, the muscles trying to hold the increasingly forward-shifted trunk upright are fighting an ever more difficult mechanical battle.
The Japanese researchers measured this. According to the programme, healthy older people in their comparison had average back-extension strength of about 16 kilograms, whereas the ASD patients averaged about 11 kilograms, roughly 70 per cent as much. Worse still, these weaker muscles were working disproportionately hard during standing and movement.
Weakness encourages stooping. Stooping increases the muscular demand required to remain upright. The muscles fatigue. The person moves less. The muscles become weaker still.
Eventually we look at the result and call it old age. I think we should be trying to interrupt that process decades earlier.
The challenge is not merely keeping older people alive. It is keeping them upright, mobile, capable and independent.
I have been calling it the T-Rex walk
Long before my accident in Chile made this issue very personal, I had been writing about these gradual changes in posture and walking. In my earlier article, Are You a T-Rex Walker?, I described what I call the "old-age thoracic slump".
As the buttock and thoracic muscles weaken, the body increasingly folds forwards. The head and upper body move ahead of the normal centre of gravity and the person begins making compensations simply to remain balanced. One is particularly easy to recognise once you know what to look for. The arms may hang passively or become tucked behind the back, sometimes with a handbag acting almost as a counterweight to the forward-projecting upper body. The stride shortens and may eventually become a shuffle. That reminded me of our depictions of Tyrannosaurus Rex, with its enormous tail counterbalancing the body in front.
This is more than an amusing description. The shuffling walker is more likely to catch a toe and fall, while arms tucked behind the body are poorly positioned to recover balance or protect the person if she does fall. In somebody with osteoporosis, the consequences can be catastrophic.
I saw this with my mother, Maisie, during her later years. Her walking deteriorated towards a shuffle and one side did not move as freely as the other. She developed the habit of walking with her arms behind her back, often with her handbag there as well. Rather than accepting that this was simply how an elderly woman walked, we got her Nordic walking. The poles encouraged reciprocal movement between the arms and legs and helped restore something closer to a proper stride. We deliberately exaggerated the walking pattern because I wanted her nervous system practising a confident stride rather than practising a shuffle.
The message I gave readers then was simple: don't be a dinosaur. Stand tall and march.
My accident has given me a much more personal appreciation of just how powerful the forces pulling us in the opposite direction can become. I explain this in my article: Are you a t-rex walker?
Don’t be a dinosaur. Stand tall and march.
This is my bread and butter
Physical conditioning, exercise therapy and rehabilitation are not new territory for me. They have been my bread and butter for more than fifty years. During that time I have assisted many thousands of people with their physical conditioning, rehabilitation following serious injuries and the prevention of the gradual loss of strength, mobility and independence that too often accompanies ageing.
I do my best to practise what I preach. My own rehabilitation has reminded me, however, that knowing what to do and consistently doing enough of it are two different things. It has also reminded me how quickly strength and posture can deteriorate following injury, and how patiently they sometimes have to be rebuilt. Rehabilitation is rarely about discovering one magical exercise. It is about applying the right exercises at the right intensity, in the right sequence, then progressing them as the body becomes capable of doing more.
For that reason, I was particularly impressed by Professor Shirado's programme. It is fundamentally sound rehabilitation. Rather than trying to force a bent spine straight, the exercises target the muscular system supporting the spine and pelvis, including the back, abdominal and deeper trunk muscles, while also addressing the hips and lower body. Importantly, the programme is progressive and adjusted according to the person's condition.
The results reported in the programme deserve attention. A 78-year-old woman underwent six months of mainly exercise therapy. Her spinal curve became milder, while the distance she could walk in six minutes increased from just 60 metres to 330 metres. Her walking speed increased from 0.96 to 1.56 metres per second.
In a group of 52 people with ASD undertaking three months of exercise therapy, the programme reports improvement in difficulty with daily activities in about 46 per cent, while roughly 52 per cent reported reductions in pain and numbness. Baba continued her exercises for ten months, after which her X-rays showed substantial improvement in her forward curvature, along with better head position and overall balance.
Professor Shirado's message is particularly encouraging. Even when severe structural deformity cannot be completely corrected through exercise, strengthening remains worthwhile because older people can still improve muscular capacity and quality of life.
That is rehabilitation I understand.
Rehabilitation is rarely about one magical exercise. It is about applying the right exercise, at the right intensity, then progressively doing more.
But we must respect fragile bones
There is an important caution here.
Many years ago, I was contacted by another health professional, an older female doctor, although younger than me, I should add. She had a rather unusual problem. Her husband had given her an enthusiastic hug and, in the process, fractured two of her ribs.
There was not a great deal anybody could do for the fractures themselves. Broken ribs generally have to be given time to heal, with appropriate attention to pain and breathing. What interested me was what this incident told us about the vulnerability of her skeleton. An ordinary affectionate embrace should not result in two fractured ribs.
I tell this story because we must be careful when recommending exercise to somebody with established osteoporosis. Bone requires mechanical loading if we want it to remain strong. Muscle requires resistance if it is to become stronger. But there is an enormous difference between applying enough stress to stimulate adaptation and applying more force than a weakened structure can safely tolerate.
This is where enthusiasm can become dangerous. A strong woman in her fifties may tolerate exercises that would be entirely inappropriate for a frail woman in her eighties with severe osteoporosis and previous vertebral compression fractures. We should not take somebody who has spent twenty years becoming progressively weaker and suddenly have her jumping, lifting heavy weights or performing aggressive spinal movements because she has read that impact and resistance exercise are good for osteoporosis.
The principle may be right while the dose is completely wrong.
This is one reason I like the exercises demonstrated in Professor Shirado's programme. They provide a relatively gentle starting point. For somebody with diagnosed osteoporosis, previous fragility fractures, substantial spinal deformity, neurological symptoms or unexplained back or rib pain, however, I recommend individual assessment before substantially increasing the exercise load.
For people who want to take this further, this is precisely the kind of work I have been doing throughout my professional life. I can assess how somebody stands, walks and moves, identify where strength and mobility have been lost, and then progressively adapt exercises such as those demonstrated in the Japanese programme to that person's circumstances. If you think I may be able to help you personally, please complete and submit this health questionnaire, and I will reply with my recommendations on the best way forward.
We start with what the body can safely manage today. Then we earn the right to progress.
Exercise is only half of rehabilitation
There is another part of this story that the television programme understandably spends less time discussing: nutrition.
We cannot repeatedly ask an ageing body to manufacture stronger spinal muscles, tendons, ligaments and bone without supplying the raw materials required to build them. This takes us back to the previous article in my osteoporosis series. Exercise supplies the stimulus, but nutrition supplies the building materials and recovery provides the opportunity for construction to take place.
Bone requires much more than calcium. It has a collagen framework that requires adequate protein, while its mineral architecture depends upon calcium, magnesium, phosphorus and numerous trace minerals working in concert. Muscles need complete protein and sufficient energy. Tendons, ligaments, fascia and other connective tissues require the amino acids and micronutrients involved in collagen production and maintenance.
As we grow older, this becomes more important, not less. We may consume fewer calories, but the nutrient density of those calories needs to improve. An elderly person cannot afford to live on tea, toast and a handful of tablets while simultaneously expecting exercise to rebuild a body that has been deteriorating for decades.
My approach is therefore straightforward: nourish the body, challenge it appropriately, allow it to recover, then progressively challenge it again.
That is how adaptation works. I will cover this topic of nutrition in a dedicated article within this series about osteoporosis.
We cannot ask an ageing body to build stronger bone, muscle, tendons and ligaments without supplying the raw materials required to build them.
A static X-ray does not tell the whole story
Another aspect of the NHK programme particularly interested me because it parallels an argument I have been making throughout this osteoporosis series: a medical image can provide important information without necessarily telling us how the person functions in the real world.
An X-ray captures posture for a fraction of a second. The Japanese researchers found that some patients could consciously straighten themselves while being X-rayed, particularly in the unfamiliar surroundings of a hospital. Yet after several minutes of walking or standing at home, muscular fatigue allowed the spine to collapse forwards again. One person shown walking appeared reasonably upright initially, but after ten minutes the back progressively rounded.
This is an important lesson. I want to know what somebody looks like after ten minutes of walking, not merely while posing for ten seconds. Can she maintain an upright posture while preparing dinner? Can she walk around the supermarket without progressively folding forwards? Can she climb stairs? Can she stand on one leg? Can she get out of a chair? Can she get herself off the floor?
These are measures of a living person rather than a snapshot.
I want to know what somebody looks like after ten minutes of walking, not merely while posing for ten seconds.
A simple check you can do at home
Professor Shirado's team demonstrates a remarkably simple screening exercise. Stand with your heels, buttocks and shoulders against a wall and see whether the back of your head can comfortably touch the wall. If it cannot, the programme suggests that kyphosis may be present and further assessment may be worthwhile. This is a screening observation, not a diagnosis.
I would go further and suggest occasionally looking at yourself side-on in a photograph. Where is your head relative to your shoulders and hips? Have you lost height? Are your shoulders progressively rounding? Is your stride becoming shorter? Are you beginning to shuffle? Do you habitually stand with your hips and knees slightly flexed? Can you march?
Do not wait until the changes are dramatic before taking notice.
Work against gravity every day
Gravity never takes a day off, and neither should our awareness of posture.
Those of us who spend our working lives at computers need to get out of our chairs frequently, straighten our hips, open our chests, bring our heads back over our shoulders and remind the muscles along the back of the body that they still have a job to do. Cyclists like me need to recognise that spending hours folded over handlebars has consequences unless we deliberately provide the opposite stimulus away from the bicycle.
Strengthen the legs. Strengthen the buttocks. Strengthen the back. Maintain hip mobility. Practise standing tall. Walk with a confident stride and allow the arms to swing. Carry things. Lift appropriate weights. Get down onto the floor and retain the ability to get yourself back up.
If osteoporosis or significant spinal deformity is already present, begin carefully and obtain professional guidance. There is no prize for injuring yourself while trying to become stronger. The objective is not heroic exercise. It is consistent, appropriate exercise for the rest of your life.
Gravity never takes a day off, and neither should our awareness of posture.
Please watch the whole programme before beginning
The exercise section of the NHK programme begins at about the 24-minute mark, and once you have watched the programme in full, I suggest returning to that section regularly. It provides an excellent visual reference for the exercises Professor Shirado and his colleagues are using with people suffering from adult spinal deformity.
However, please do not simply jump straight to the 24-minute mark and start copying the exercises. Watch the entire programme first. The preceding material explains what adult spinal deformity is, what is happening to the muscles supporting the spine, how osteoporosis and vertebral fractures can contribute, and why these particular exercises have been selected.
Once you understand the programme, return to the exercise section and use it as a reference. Begin gently. Pay attention to technique. Do not assume that because an exercise looks easy it is necessarily appropriate for your particular spine. If you have osteoporosis, previous compression fractures, significant spinal deformity or pain, get experienced professional guidance before progressing.
There is much more to this subject than I can responsibly cover in one article. In further articles in this series I will explain more about the remarkable process by which living bone is continually broken down and rebuilt, including the roles of osteoclasts and osteoblasts. I will also examine the role of medications that alter this remodelling process and where I believe considerable caution is warranted.
Nutrition deserves much more attention as well. Rebuilding bone requires far more than calcium and vitamin D. We need to consider complete protein, collagen, minerals and their relationships, fat-soluble vitamins, healthy fats, digestion, inflammation and the overall nutritional state of the person. I will delve much more deeply into these subjects in articles to follow.
So please be patient with me. These articles take time to research and write, and this is a subject that cannot responsibly be dealt with in brief bullet points. More importantly, please be patient with your own body. If your posture and bone strength have deteriorated over twenty or thirty years, do not expect to reverse the process in twenty or thirty days.
My experience following my accident has driven this lesson home more forcefully than I would have wished. For a period I could actually feel my thoracic spine wanting to collapse forwards, and I felt remarkably powerless against it. Time, healing, carefully progressed exercise, good nutrition and constant postural awareness are gradually changing that. I am standing straighter and becoming stronger, although the job is far from finished.
When it comes to restoring bone strength, posture and our general sense of health and wellbeing as we grow older, I have always preferred the tortoise to the hare.
Start where you are. Do a little regularly. Nourish yourself well. Rest adequately. Then gradually do a little more.
Do not wait until you are eighty, staring at the pavement and depending upon a walking frame before deciding to strengthen the muscles responsible for keeping you upright. Start now. If you are already eighty, start where you safely can. Professor Shirado's work gives us good reason not to assume that improvement has an expiry date.
We cannot stop the clock, and we cannot completely defeat gravity. But we can make gravity work a great deal harder.
Stand tall, keep moving and keep giving your body a reason to remain strong. The objective is not to win the race next month. It is to still be standing tall and moving confidently many years from now.
If your posture and bone strength have deteriorated over twenty or thirty years, do not expect to reverse the process in twenty or thirty day.
Further viewing and reading
The NHK WORLD-JAPAN programme that inspired this article is Straightening a Bent Spine Through Exercise. I strongly recommend watching the entire programme first and then returning to the exercise demonstration from approximately 24 minutes whenever you need to refresh your memory.
Tai chi is a safe and effective form of exercise to incorporateand to one's daily routine. Dancing - ballroom-style - is another great form of postural exercise.
When restoring bone strength, posture and health as we grow older, I prefer the tortoise to the hare. The objective is not to win the race next month. It is to still be standing tall and moving confidently many years from now.
Medical Disclaimer
This information is provided for educational purposes only and reflects my professional experience and interpretation of the subject. It is not intended as personal medical advice, diagnosis or treatment. Adult spinal deformity, osteoporosis, vertebral compression fractures and persistent spinal pain require appropriate professional assessment. Exercise must be matched to a person's present bone strength, physical condition, balance, injuries and fracture risk. If you have osteoporosis, previous fragility fractures, substantial spinal deformity, neurological symptoms or significant pain, consult an appropriately qualified healthcare professional before beginning or substantially changing an exercise programme.
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