Stability, Tone, Symmetry, and Flexibility: What You Need to Know to Keep a Healthy Spine

By Gregg Squeglia

Firefighters, EMTs, and paramedics know that one of the biggest risks of getting hurt on the job is from lifting patients during rescue or EMS operations. The working conditions at the time of injury are often less than ideal. Lifting in tight spaces, overweight patients with little bone structure to grab, or the time constraints of a rescue situation all make this task difficult, and it often gets repeated several times each shift. These professionals know that in order to keep from getting hurt, they need to keep fit for duty, including keeping a strong back and core muscles.

But is that all there is to keeping a healthy back? If we just load the muscles with resistance over time, will it really prevent injury? The truth is that while strength is an important component to preventing a back injury, there is more to it. We need to consider the concepts of stability, tone, symmetry, and flexibility. These need to be incorporated into a firefighter’s or EMT’s personal fitness program, starting now.

Let’s first take a look at strength. You can visualize strength as the ability to exert a force and move an object or person. When you lift a loaded stretcher into the ambulance, you are demonstrating that you have sufficient strength in the larger muscles of the legs, spine, and arms to do that particular task.

Stability is quite different than brute strength. Stability is your body’s ability to exert a force in order to resist movement, particularly the ability to keep your spine from contorting out of the neutral position during a lift. Anybody that has experience with paddling a canoe or stand up paddleboard will understand stability. As the arms row backward, pushing water, the abdominal muscles contract to keep the spine from becoming bent backward (hyper-extending). This makes the paddle stroke more efficient and prevents undue stress on the lower back. Core instability is when the spine is unable to hold itself steady when a force is placed on it. We can even sometimes see core instability in people walking down the street, shoulders and trunk swaying from side to side with each step. These individuals certainly have enough muscle strength to keep from swaying: it does not take much effort. But they continue to sway because the motor programming in their brain is not working correctly. The smaller stabilizer muscles are not firing effectively to brace against the impact of the foot hitting the ground.

Let’s now bring this concept back to fire and EMS operations. When a firefighter holds a hose against the force of the exiting water, he must fire not only the larger abdominal muscles to keep from getting blown backward (especially if he’s wearing self-contained breathing apparatus), but a lot of other smaller muscles which keep the spine from bending out of shape. The ability to do this is more neurologic than muscular, meaning that doing abdominal crunches and sit ups have limited effectiveness at making this happen. There is a learning process in the brain that has to take place. It can be done through specific exercises and training, but these exercises generally do not create washboard abs or impressive photos and are thus often neglected. We will discuss a few exercises later on how to create greater spinal stability.

Tone is a muscle’s ability to sustain a minimal contraction, even while at rest when you are not trying to use it. In the trunk area, the core musculature should have a small amount of contraction while standing at rest. This allows the spine to remain in a relatively neutral position without excessive stresses and not crumble under the force of gravity. Generally, the inability to create sufficient tone leads to a swayback posture or excessive curvature in the lower back while standing. The belly often will protrude as well. All of this muscle contraction serves another purpose. It creates pressure within the abdominal cavity, lifting the weight of the upper body off of the lower spine and transmitting it directly to the hips. Think of your abdominal area as a hydraulic system, similar to a car jack. With a jack, as the handle is depressed, hydraulic fluid is compressed, which pushes on a piston, in turn lifting the weight of the car upward. The same is true in your body. As the abdominal musculature tightens even with sedentary activities such as standing still, it compresses the contents of the belly and increases pressure, allowing the weight of the upper body to rest on top of it. This weight is borne directly by the hips and pelvis, allowing the more delicate structures of the lower spine some rest. This is a critical concept to grasp in terms of keeping a healthy spine and is a major reason that sitting activities are often just as damaging to the spine as more intensive standing activities such as lifting. As we sit, we tend to relax the abdominal musculature and rest on our spinal ligaments, allowing the full weight of the upper body to be borne by the lower back. The load essentially doubles when we are sitting. What this means is that over time, if a firefighter has poor muscle tone, the vehicle rides to the EMS calls could be just as damaging as the actual patient lifts.

The next concept to be aware of is muscular symmetry. Simply put, the left side of the body needs to be able to generate equal force as the right side of the body. But because we are all either right- or left-side dominant, we tend to have unequal strength and unequal flexibility. Think of a radio antenna that stations use to broadcast a signal. Attached to the antenna are several guy wires, which provide the strength and stability needed to resist the force of wind. Each wire is tensioned appropriately so that the force through the antenna is equal on all sides and directed straight into the ground. If tension on one wire were tightened or loosened, it would create weak spots in the antenna, perhaps even making it list to one side. Your spine is that antenna, and the muscles surrounding it are the guy wires. Tight muscles or weak muscles, compared to the opposite side, can cause any load that is being lifted to be borne unequally in the spine. Over time this leads to arthritis or failure of the spinal discs. The spine has an optimal position in which to work, called the neutral spine. In this position, the weight through the spine is distributed equally through the spinal discs and the joints that connect one vertebra to the next are not excessively compressed. It is important to be able to maintain this position, if possible, when doing strenuous tasks such as lifting patients or equipment or swinging kettlebells at the gym. Maintaining proper muscle symmetry and strength ratios between the left and right and front and rear sides of the trunk will help in achieving that goal.

Now we come to the issue of flexibility. We all know that we should have decent flexibility and that we should stretch our muscles, but this is generally the part of our workouts that is most neglected. We may have one hour to exercise, and almost all of that time is used up with resistance or cardiovascular training. We leave ourselves with very little time to stretch. But as we go through life and our bodies age, we experience small amounts of damage to our muscle tissue. In medical lingo we call this microtrauma. A muscle fiber breaks here, another one there. Most often we don’t even feel it happening. It is important to note here that the body does not make more muscle fibers. You were born with all of the muscle fiber that you will ever have. Each muscle fiber can become thicker, which is why weight lifting can produce greater muscle mass, but the number of muscle cells does not change. Now, the body will repair the damage caused by microtrauma by filling the break with scar tissue, which is a much less flexible material than the muscle tissue that is replaced. As the years go on, this scar tissue accumulates and makes us stiffer, weaker, and more prone to injury. This is why stretching and maintaining adequate flexibility is so important. It may not prevent us from getting old, but it can keep us from feeling old.

Tight muscles in the lower back, hips, and thighs also alters the position of the spinal column, especially as we move and do work. Tight hamstrings in the back of the thigh for instance, will limit the pelvis from bending forward as one reaches to the floor. This lack of motion at the hip means that the spine must pick up the slack, bending excessively out of the neutral spine position and putting the lower back in danger of sustaining a pulled muscle or a herniated disc (ouch!).

Implementing this information at the gym and on the job will take some time and training, but here are a few tips to get you started.

1. Stability Ball Mountain Climber Exercise: This exercise is a great way to build strength and stability within the rectus abdominus (six-pack muscles) and the transverse abdominus. The transverse abdominus has gotten quite a bit of press in the rehab literature in recent years because of its role in keeping the lower back free of injury. For this exercise, use a large stability ball (75cm diameter should be sufficient for most adults). Place both hands on top of the ball and then walk your feet back until your torso is in a generally straight line. The starting position that you should be in is an incline plank. Then lift one knee toward your chest while keeping your back straight. Lower and repeat on the opposite side. Do 10-15 repetitions, but make sure to stop if you feel your back sagging. You must keep your back straight in order to benefit.

Stability, Tone, Symmetry, and Flexibility: What You Need to Know to Keep a Healthy Spine

2. Hamstring Stretch: You will not always perform a full squat when lifting or reaching to a lower height. Many times it will be impractical, such as with reaching into a vehicle during an extraction operation. But you still need to keep a neutral spine if at all possible. By keeping the hamstrings flexible, the pelvis is free to rock forward and allow the spine to maintain much of its original shape. Sit on the floor with one leg outstretched, the other tucked into your groin. Now gently reach forward toward your outstretched knee (or lower leg, depending on your flexibility) until you feel a stretch behind the knee and up the back of the thigh. Hold this for 30 seconds and repeat three times on each side.

3. Jumping Rope: If your department does not have a few jump ropes laying around, do yourself a favor and pick one up for yourself. There are several benefits to jumping rope, including high calorie burn and the portability of the exercise. In terms of spinal health, the key factor is that when you are jumping rope, the stabilizer muscles are working as they are designed to work. With a bit of practice, the core stabilizers will become more efficient and you will feel rather relaxed through the trunk. Although frequently getting the rope caught under the toes can be frustrating at first, it is worth the time to learn to do it well. Gray Cook, physical therapist and rehab guru, explains the benefits of this exercise in detail in his book Athletic Body in Balance. Click here for the excerpt on jumping rope.

4. When doing resistance training, incorporate the abdominal and lower back muscles into your exercises. Keep a neutral spine as you lift weight. Here is an example: If doing seated incline presses, try to maintain only a slight arch in the lower back and prevent the small of the back from arching off of the bench. If you cannot maintain this position, then you are probably lifting too much weight. In this case, you are substituting your middle pectorals for your weaker or fatigued upper pecs and shoulders anyway. You are also wasting a great opportunity to work the core muscles at the same time. Drop weight until you can hold neutral spine, then build back up using proper form. Another way to work the core muscle into a workout routine is by using a suspension training system, a piece of equipment that uses body weight at various angles to apply resistance to any body part. Because the body is standing or outstretched for most of the workout, almost all exercises become core-stability exercises. 

Hopefully all this makes perfect sense. But if not, feel free to leave your comments below or send me an e-mail directly at

Gregg Squeglia has been a practicing physical therapist for 16 years, with much of that time dedicated to the management and treatment of worker compensation injuries. He graduated from the University of New England in 1996 and has taken advanced training in functional capacity evaluations, physical demands analysis, and implementation of injury prevention programs. Squeglia has delivered classes and lectures on injury prevention to private companies and government agencies and has developed the Fire & EMS Injury Prevention Program, tailored to meet the unique physical demands of this industry. He also serves as a military intelligence officer in the Army National Guard and is an Iraq War veteran.

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