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Supplemental Digital Content File 1

Prescription Guidelines for Classification-Specific and Non Classification-Specific Treatment Conditions

Condition Treatment component

Prescription

Overall

recommendations

Frequency and Progression

Classification-

specific

Exercises,

activities, and

positions for control

of symptoms

Perform as frequently as

possible across day to

avoid onset or increase (if

present) of symptoms

Perform each item as

prescribed a minimum of 4

times/day

Exercises for

precision and

control of

movement

Perform at least 1 time/day

and up to 2 times/day

Prioritize control of

movement over number of

repetitions

Avoid increase in

symptoms with

performance

Perform each prescribed

exercise a minimum of 5

repetitions

Progress to 10

repetitions/exercise if

able to perform

movement correctly

without an increase in

symptoms

Progression is based on

independence in

performance* and ability

to perform 10 repetitions


symptoms¶

Performance of

functional activities

Perform activities as


time/day and up to 2

times/day

Incorporate principles of

movement and posture

modification into all

activities across the

day¶¶


activity a minimum of 5

repetitions

Progress to 10

repetitions/activity if able

to perform correctly and


symptoms

Progression of activity is

based on independence

in performance* and

ability to perform 10

repetitions without

increase in symptoms¶

Non classification-

specific

Exercise for

strength and

flexibility

Perform prescribed

strengthening exercises 3-

5 times/week

Perform prescribed

flexibility exercises 2-3

times/week

Strengthening: Perform 3

sets of each exercise

beginning with 5

repetitions, progressing to

10 repetitions per set

Flexibility: Perform 3-5

repetitions/exercise; hold

each stretch minimum of

30 seconds

Performance of

functional activities

Perform activities as


time/day up to 2 times/day

Incorporate principles of

movement and posture

modification into all

activities across the

day¶¶


activity a minimum of 5

repetitions

Progress to 10

repetitions/activity if able to

perform correctly

Progression of activity is

based on independence in

performance* and ability to

perform 10 repetitions

*Independence in performance was based on a therapist’s judgment of the participant’s performance at a clinic visit.

The therapist judgment was based on defined criteria (Harris-Hayes et al., 2010).

¶ A primary difference between the two treatment conditions was that participants in the Classification-specific

condition were instructed so as to perform exercises and activities without an increase in symptoms, and symptom

behavior was one determinant of progression to a (1) more difficult level of exercise or activity, or (2) new exercise or

activity. In the Non classification-specific condition symptom behavior during the exercises or activities did not guide

prescription and progression.

¶¶ Recommendation is the same for the two treatment conditions.

Classification-Specific ConditionLumbar Extension-Rotation

Educational Concepts

1. The primary contributors to your low back pain symptoms are 1. Repeated movements of your low back into extension and

sidebending or rotation. 2. Prolonged positions of your low back in extension and

sidebending or rotation.2. The repetition of movements and positions of your low back in

extension and sidebending or rotation occurs across your day during all of your daily activities.

3. The repetition of movements and positions of your low back in extension and sidebending or rotation keeps your low back region irritated and results in low back pain symptoms.

4. The low level of irritation of tissues in your low back region that is the result of moving in the same direction all day makes it easy for your low back pain symptoms to persist or recur.

5. The emphasis of your treatment is on learning how to modify or change how you perform your daily activities so you do not extend and rotate or side bend your low back repeatedly across your day.

6. It is important to remain active.

These changes eliminate the irritating movements and positions (extension and rotation or sidebending) to tissues in your low back.

Correct sitting position- Back is relaxed.

Too much extension in low back.

Too much extension in low back.

Lumbar Extension-RotationControl of Symptoms: Exercises, Activities and Positions

General Guidelines:

These activities should be performed frequently throughout the day to avoid onset or increase of your symptoms.

Minimum 4 times per day. You should not feel an increase in your symptoms with these activities. If you do, please contact your physical

therapist.

Activity: Push-Up in Sitting

Movement: Sitting in a chair with hands on armrests or surface of chair. Lean forward slightly. Use hands to push up and unweight the low back.

Do Not: Extend your low back as you lift up.

Key Concept: Unweight low back.

Activity: Sitting – Flatten Low Back

Do: Pull in your abdominals and flatten your low back against the chair. Relax your back and hip muscles. You may want to perform the push up activity first.

Do Not: Tighten muscles in your low back or hips.

Key Concept: Flatten low back.

Activity: Sitting Position

Do: Have support behind the low back. Low back and legs should be relaxed. You may need support under your feet if your chair is too high.

Do Not: Sit with the low back extended or in rotation, sidebending or shift.

Key Concept: Keep low back flat; do not rotate, side bend or shift low back.

Activity: Get Up Frequently

Do: Get out of sitting position every 30 minutes and either stand or walk. You may want to set a timer to remind yourself.

Key Concept: Change load on the low back.

Activity: Standing – Small Squat

Do: Pull in your abdominals to round your back. Bend your hip and knees slightly. Once symptoms decrease, hold the abdominals as you straighten your knees.

Key Concept: Flatten low back.

Activity: Standing – Flatten Low Back Against the Wall

Do: Stand with your back to the wall using the wall as a support to unload the low back. Contract your abdominals and flatten your low back against the wall.

Do Not: Contract your back muscles. Rotate, side bend or shift the low back.

Key Concept: Relax back to wall.

Activity: Quadruped - Position

Do: On a stable surface, get into hands and knees as shown in the picture. Hips should be positioned directly over the knees. Contract your abdominals and round the low back.

Do Not: Rotate, side bend or shift the low back.

Key Concept: Round low back.

Activity: Quadruped – Rock Back

Do: On a stable surface, get into hands and knees. Contract your abdominals. Using your hands to push, rock back so your hips move over your heels. Stop before any rotation or side bend of low back, or increase in symptoms.

Key Concept: Push with hands.

Activity: Quadruped – Rock Back (Limitation in Hip)

Do: On a stable surface, get into hands and knees. Place your limited hip out to the side. Contract your abdominals. Keeping your hands in place, rock back so your hips move over your heels. Push with your hands to rock back. Stop before any rotation or side bend or increase in symptoms.


Push back with hands.

Push back with hands.

Activity: Standing With Feet Apart

Do: Stand with your feet shoulder width apart. Keep weight evenly distributed over both feet.

Do Not: Stand with your weight shifted onto one foot. Rotate, side bend or shift the low back.

Key Concept: Equal weight bearing.

Activity: Side Stepping

Do: Stand with your feet shoulder width apart and your knees slightly bent.Make sure that your feet are pointing straight ahead and are in line with each other. Step straight out to the side within a comfortable step length. You may want to use a line on the floor or the wall to make sure that you do not step forwards or backwards.

Do Not: Let your pelvis drop when you step to the side. Rotate, side bend, or shift in your low back.

Key Concept: Keep pelvis level.

Activity: Standing – Leaning Into Counter

Do: Stand at a counter that is just above waist level. Place your hands on the counter to support the weight of your upper body. Contract your abdominals. Rock back rounding your low back.


Activity: Standing – Full Squat

Do: Squat down in order to round out the low back.


Activity: Standing – Leaning Forward

Do: Lean forward and place your hands on your thighs to round the low back.To stand back up – sway your upper body back and bring your pelvis forward to maintain the round back.

Do Not: Extend the low back.


Activity: Standing – Sitting on Edge of Counter

Do: Lean back into a partial sitting position with your seat resting on the edge of a surface. Surface used should be stable and allow for the hips to bend and low back to be rounded.


Activity: Back Lying Position

Do: Place 2-3 pillows under the knees so that your low back flattens. Relax your legs.

Do Not: Lift both legs at the same time.


Activity: Abdominal or Back Support

Do: Apply the brace while lying down or with your back against the wall. Use as needed to control symptoms.

Key Concept: Supports low back to stop sidebending, rotating and shifting.

Lumbar Extension-RotationExercises for Precision and Control of Movement

Exercise: Forward Bend and Return

Movement: Hip Extension with Flat Lumbar Spine and Hand Support

Purposes:-To improve ability to move in hips without excessive arching of the lumbar spine.-To improve the performance of the gluteal muscles.

Method:-Stand next to a table on which you can rest your hands.

Key Concept: Do not arch back.


Method (cont.):-Place your hands on the table.-Try to put the weight of your upper body on your hands.-Let your elbows and knees bend.-To begin the return movement, tighten the muscles in your buttocks. Do not arch your back.-As you are moving upward, be sure to keep moving in your hips.-Do not allow your pelvis to sway forward or your upper trunk to sway backward at the end of the range.


WARNING:-Do not arch your back when you are going either up or down.

Exercise: Standing Flatten Low Back

Movement: Posterior Pelvic Tilt and Flattening of Lumbar Spine in Standing

Purposes:-To improve the performance of the abdominal muscles.-To flatten lumbar curve.-To stretch the hip flexors.

Method:-Stand with your back against a wall.-Place your heels about 3 – 6 inches (8 – 15 cm) away from the wall.-Bend your knees and hips enough that you can flatten your low back against the wall.-Make sure your low back is flat even if it means your upper back and shoulders are leaning forward.-Contract your abdominal muscles by pulling your navel toward your spine.-Be sure to keep contracting your abdominal muscles while you are moving yourself upward.

Key Concept: Relax low back against the wall.

Exercise: Hook Lying – Hip Flexor Stretch (left side)

Movement: Hip and Knee Extension with Opposite Hip and Knee Maximally Flexed.

Purposes:-To stretch hip flexors. -To improve the control of the pelvis by the abdominal muscles.

Method:-Bend your hips and knees but keep your feet flat on the surface. -Place your fingers on your abdominal muscles between your pelvis and ribs at both sides of your body. -Contract abdominal muscles by pulling your navel toward your spine.

Key Concept: Keep low back flat.


Method (cont.):

-Lift your right knee toward your chest.

-Use your hands to hold your right knee close to your chest. You may need to use a towel wrapped around the thigh to assist with this motion.

-Maintain the contraction of your abdominal muscles all the while you are pulling your knee up and holding it toward your chest.


Method (cont.):-Make sure your abdominal muscles are contracting. -Slide your left foot away from you so that your leg straightens out and is flat on the surface. -Stop immediately if you get pain in your back or if your pelvis tilts forward. -Place pillows under the leg you are straightening to control symptoms. -Make sure your abdominal muscles are contracting. -Return to the starting position by sliding your left foot toward your buttocks and by allowing your right foot to return to the table. Dig your heel into the support surface to decrease hip flexor activity as you return your straightened leg to the starting position. -Repeat by bringing your left knee to your chest and sliding your right foot away from you.

Exercise: Hook Lying – Leg Slides

Movement: Hip and Knee Extension from Hip and Knee Flexion.

Purposes:-To stretch hip flexors. -To improve the control of pelvic tilt by the abdominal muscles.

Method:-Lie on your back with hips and knees bent and your feet flat on the floor. -Place your fingers on your abdominal muscles between your pelvis and ribs on both sides of your body. -Contract abdominal muscles by pulling your navel toward your spine.



Method (cont.):-Slide the heel of your right leg away from you so that your leg straightens out and is flat on the table. -Be sure to keep your pelvis from moving while you are sliding your foot.-Stop immediately if you get pain in your back or if your pelvis tilts forward.


Method (cont.):-After your leg is straightened, if you do not have pain, then slide your left (other) leg down. -Return to the starting position by first sliding one foot back toward your buttocks and then the other foot. Dig your heel into the support surface, particularly if there is an increase in symptoms. -Be sure to contract your abdominals whenever you are moving your legs.-If your therapist said it would help, place a pillow under your upper back and head. -Position a pillow under one knee and perform hip and knee extension with the opposite leg.

Exercise: Hook Lying – Leg Slides with Arms Overhead

Movement: Hip and Knee Extension from Hip and Knee Flexion


Method:-Lie on your back with your hips and knees bent and your feet flat on the floor.-Place your fingers on your abdominal muscles between your pelvis and ribs at both sides of your body. -Contract abdominal muscles by pulling your navel toward your spine.



Method (cont.):-Slide the heel of your right leg away from you so that your leg straightens out and is flat on the table.-Be sure to keep your pelvis from moving while you are sliding your foot. -Stop immediately if you get pain in your back or if your pelvis tilts forward.


Method (cont.):-After your left leg is straightened, if you do not have pain, then slide your left (other) leg down.-If there are no symptoms with one leg completely extended, lift arms overhead without allowing the low back to extend.-Return to the starting position by first bringing your arms back to your sides. Then slide one foot back toward your buttocks and then the other foot. Dig your heel into the support surface, particularly if there is an increase in symptoms.-Be sure to contract your abdominals whenever you are moving your legs.-If your therapist said it would help, place a pillow under your upper back and head.

Exercise: Hook Lying – Hip Abduction/Lateral Rotation

Movement: Hip Abduction/Lateral Rotation from Flexion Position

Purposes:-To improve the isometric performance of the abdominal muscles in preventing pelvic rotation.-To move the leg without movement of the pelvis.-To stretch the hip adductor muscles (inner thigh muscles).

Method:-Lie on your back with your hands on your pelvis. -Place a small towel roll behind your back.-Bend your left knee and hip but keep your foot on the surface.-Keep your right knee straight.

Options:-Place a pillow under your right knee.-Place a pillow along the side of your left leg.

Key Concept: Do not let pelvis move.


Method (cont.):-Contract your abdominals by pulling your navel toward your spine.-Let your left knee move out the side (away from your trunk).


Method (cont.):-Do not let your pelvis move while you are moving your left leg. -Perform all repetitions with one leg and then repeat with the other leg.

Exercise: Hook Lying – Hip Abduction/Lateral Rotation Progression 1

Movement: Hip Abduction/Lateral Rotation from Flexed Position: Knee Extended

Purposes:-To improve the isometric performance of the abdominal muscles in controlling pelvic rotation.-To move the leg without movement of the pelvis or spine.

Method:-Lie on your back with your hands on your pelvis. -Bend your left knee and hip but keep your foot on the surface.-Keep your right knee straight.



Method (cont.):-Contract your abdominals by pulling your navel toward your spine.-Let your left knee move out to the side (away from your trunk).


Method (cont.):-With your left leg out to the side, pick up your foot and straighten your knee. -Do not push down with your right (non-moving) leg.-Do not let your pelvis rotate.-Hold your knee straight for a few seconds, then bend your knee again and let your foot rest on the surface.-Bring your left knee back to the upright position.-Straighten your left hip and knee.-Repeat the entire sequence with your right (other) leg.




Method:-Lie on your back with your hands on your pelvis. -Bend your left knee and hip but keep your foot on the surface.-Keep your right knee straight.-Contract your abdominals by pulling your navel toward your spine.-Let your left knee move out to the side (away from your trunk).-With your left leg out to the side, pick up your foot and straighten your knee.-After straightening your knee, move your leg toward your right (opposite) shoulder by moving at your hip.-Do not let your pelvis move while you are moving your leg.-Move your leg back away from your right (opposite) side and back out to the left.-Bend your left knee and let your foot rest on the surface.-Bring your left knee back to the upright starting position.-Straighten your left hip and knee so that your entire leg is flat on the surface.-Repeat the entire sequence beginning with your right (other) leg.


Exercise: Prone – Knee Flexion (left side)

Movement: Knee Flexion in Prone

Purposes:-To decrease the compensatory motion of the pelvis and spine.-To increase the flexibility and stretch the quadriceps and tensor fascia latae muscles.-To improve the performance of the abdominal muscles.

Method:-Lie face down with your legs straight and relatively close together.-If your therapist said it would help, place a pillow under your abdomen.



Method (cont.):-Place your hands on your buttocks or on the front of your pelvis so you can tell if the pelvis is moving.-Contract your abdominal muscles by pulling your navel toward your spine.-Bend your left knee.-Do not let your pelvis or low back rotate or tilt forward.-Do not pull so hard that you get a cramp in the back of your thigh.-Return your leg to the starting position.-Repeat the entire sequence beginning with your right (other) leg.

Exercise: Hip Lateral and Medial Rotation in Face Lying – Step 1

Movement: Hip Lateral and Medial Rotation in Face Lying

Purposes:-To decrease the compensatory motion of the lumbopelvic region during hip motion.-To improve the flexibility and stretch the hip rotator muscles.-To improve the performance of the abdominal muscles.

Method:-Lie face down with your legs straight and relatively close together.-Bend your left knee to 90 degrees.-If your therapist said it would help, place a pillow under your abdomen.


Exercise: Hip Lateral and Medial Rotation in Face Lying

Method (cont.):-If your therapist said it would help, place your hands on your buttocks or on the front of your pelvis so you can tell if your pelvis is moving.-Contract your abdominal muscles by pulling your navel toward your spine.-Bend your left knee to 90 degrees.


Method (cont.):-Rotate your hip by allowing your left foot to move in toward the right (other) leg.-Do not let your pelvis move.


Method (cont.):-Rotate your hip by allowing your left foot to move away from your right (other) leg.-Do not let your pelvis move.-Return to the starting position.

Perform all repetitions with one leg and then repeat with the other leg.

Exercise: Arm Lifts in Quadruped

Movement: Shoulder Flexion in Quadruped

Purposes:-To improve the performance of the abdominal muscles.-To improve the control of the spine in preventing rotation.-To improve balance control.

Method:-Get on your hands and knees.-Place your knees 4 – 6 inches (10 – 15 cm) apart.-Center your hips over your knees.-Bend your hips to 90 degrees.-Point your toes.-Center your shoulders over your hands.-Keep your head in line with your body.-Contract your abdominal muscles by pulling your navel toward your spine.-You can also push down and back with the hand of the stationary arm to prevent movement in the trunk.

Options:-Barely lift your left hand off the supporting surface by bending your elbow.-Rock back slightly so that the hips are bent past 90 degrees.-Lift your left arm overhead so it is parallel with the support surface.

-Do not let your trunk move or shift when lifting the arm.-Return your left hand to supporting surface.

Perform all repetitions with one arm and then repeat with the other arm.

Key Concept: Do not let the trunk move.

Exercise: Standing Lateral Bending

Movement: Lateral Spine Flexion

Purpose:-To increase the flexibility of the paraspinal muscles.-To increase the flexibility of the abdominals.-To decrease the excessive flexibility of some spinal segments.

Method:-Stand with both feet comfortably apart.-Raise your arms overhead and clasp your hands together (as in the picture) to provide an additional stretch on the side of your trunk.

Key Concept: Move in upper trunk not low back.


Method (cont.):-Stand with your back against a wall to avoid rotating your body.


Method (cont.):-TILT your shoulders to the left side.-Think about bending in the area of your chest rather than your waist.-Stop if you feel pain.-If your therapist said it would help, place your hand on your left side at waist level, between the top of your pelvis and the bottom of your ribs (as in picture).-Lean to your left side.-Return to the starting position.-Repeat to the right (other) side.

Perform all repetitions to one side before performing repetitions to the other side.

Exercise: Standing Forward Bend Curl

Movement: Hip Flexion with Thoracic and Lumbar Flexion

Method:-Stand with both feet comfortably apart.

Exercise: Standing Forward Bend Curl

Method (cont.):-Let your upper back and low back “curl” as you bend forward.OR-Let your low back “curl” as you bend forward.-Contract your abdominal muscles as you bend forward.-To begin the return movement, tighten the muscles in your buttocks.-As you are moving upward, be sure to keep moving in your hips.-Upon return to the upright position, relax with your arms resting at your sides.


Exercise: Back Lying Shoulder Extension/Adduction in Hook Lying

Movement: Shoulder Adduction while Maintaining Contraction of Abdominal Muscles

Purposes:-To improve the performance of the abdominal muscles.

Method:-Lie on your back with your hips and knees bent, so that your feet are flat on the surface and your arms are at your sides.-See second picture.-Grasp the weight your therapist told you to use.-Slide your left arm out to the side far enough that your hand is slightly above your head (see Figure).-Contract your abdominal muscles by pulling your navel toward your spine.

Key Concept: Contract abdominals.


Method (cont.):-Lift your left arm toward the ceiling and toward your right (opposite) hip. -Keep your elbow straight.-Stop moving your arm when it is pointing straight up toward the ceiling.-Return your arm to the surface.


Can progress the activity by performing the same motion in standing.

Exercise: Lower Abdominal Progression, Pre-Level 1

Movement: Hip and Knee Flexion with Opposite Leg Held toward Chest

Purposes:-To improve the isometric performance of the abdominal muscles (obliques, rectus abdominis, transversus abdominis).-To move the lower extremity without movement of the pelvis or spine.

Method:-Bend your hips and knees but keep your feet flat on the floor.-Contract your abdominal muscles by pulling your navel toward your spine.



Method (cont.):-Lift your right knee toward your chest. -Hold your knee toward your chest with your hands.-If you are able to hold your knee with one hand, place your other hand on the abdominal muscles between your pelvis and ribs at the side of your body.-Be sure the abdominal muscles are contracted.-Lift your left (other) foot off the surface to 90 degrees.


Method (cont.):-Keep your back from moving while you lift your leg.-Lower your left foot to the surface.-Keep your back from moving while you lower your leg.-Lower your right (other) foot to return to the starting position.-Repeat the entire sequence beginning with your left (other) leg.

Exercise: Lower Abdominal Progression, Level 1A

Movement: Hip and Knee Flexion with other Hip Flexed to >90 Degrees

Purposes:-To improve the performance of the abdominal muscles (obliques, rectus abdominis, transversus abdominis).-To move the lower limb without movement of the pelvis or spine.

Method:-Bend your hips and knees but keep your feet flat on the floor.-Place your fingers on your abdominal muscles between your pelvis and ribs at both sides of your body.-Contract your abdominal muscles by pulling your navel toward your spine.



Method (cont.):-Lift your right foot off the surface and bring your right knee toward your chest so that your hip is flexed more than 90 degrees.


Method (cont.):-If necessary, contract your abdominal muscles again.-Lift your left foot off the surface.-Keep your back from moving while you are lifting your legs.-Do not let your chest depress.-Do not let your abdomen distend.


Method (cont.):-While maintaining the contraction of your abdominal muscles, lower your left foot to the surface (the foot you just lifted).-Lower your right (other) foot to return to the starting position.-Repeat the entire sequence beginning with your left (other) leg.

Exercise: Lower Abdominal Progression, Level 1B

Movement: Hip and Knee Flexion with Other Hip Flexed to 90 Degrees

Method:-Bend your hips and knees but keep your feet flat on the floor.-Place your fingers on your abdominal muscles between your pelvis and ribs at both sides of your body.



Method (cont.):-Contract your abdominal muscles by pulling your navel toward your spine. -Lift your right foot off the surface and bring your right knee toward your chest so that your hip is flexed to 90 degrees.-If necessary, contract your abdominal muscles again.-Lift your left (other) foot off the surface.-Keep your back from moving while you are lifting your leg.


Method (cont.):-Do not let your chest depress.-Do not let your abdomen distend.-While maintaining the contraction of your abdominal muscles, lower your left foot to the surface (the foot you just lifted).-Lower your right (other) foot to return to the starting position.-Repeat the entire sequence beginning with your left (other) leg.

Exercise: Lower Abdominal Progression, Level 2

Movement: Hip and Knee Flexion with Foot Partially Supported

Purposes:-To improve the performance of the abdominal muscles (obliques, rectus abdominis, transversus abdominis).-To move the leg without movement of the pelvis or spine.

Method:-Lie on your back with your hips and knees bent and your feet flat on the floor.-Place your fingers on your abdominal muscles between your pelvis and ribs at both sides of your body.



Method (cont.):-Contract your abdominal muscles by pulling your navel toward your spine.-Lift your right leg up until your hip is bent to 90 degrees and your thigh is pointing toward the ceiling. -Keep your back from moving while you are lifting your leg.-Do not push down with your left (other) foot.-Do not let your chest depress.


Method (cont.):-If necessary, contract your abdominal muscles again.-Do not let your abdomen distend.-Do not push your head back into supporting surface.-Do not hold your breath.-Lift your left (other) foot so that it is only lightly touching the surface.-Slide your foot away from you until your leg straightens completely.


Method (cont.):-Contract your abdominal muscles again.-Slide your left foot back to the starting position.-Lower your right (other) foot down to the surface, so that both feet are on the surface again.-Repeat the entire sequence beginning with your left (other) leg.


Movement: Hip and Knee Extension with Foot Unsupported





Method (cont.):-Contract your abdominal muscles by pulling your navel toward your spine.-Lift your right leg up until your hip is bent to 90 degrees and your thigh is pointing toward the ceiling. -Keep your back from moving while you are lifting your leg.-Do not let your chest depress.


Method (cont.):-Do not let your abdomen distend.-Do not push your head back into supporting surface.-Do not hold your breath.-If necessary, contract your abdominal muscles again.-Lift your left (other) foot so that it is not touching the surface.-Straighten your left hip and knee completely.


Method (cont.):-Lower your left leg to the supporting surface. Rest the leg for a count of 3.-Contract your abdominal muscles again.-Lift your left foot again and move it back to the starting position.-Lower your right (other) foot down to the surface, so that both feet are on the surface again.-Repeat the entire sequence beginning with your left (other) leg.

Exercise: Trunk Curl

Movement: Trunk Flexion with Hips and Knees Flexed

Purposes:-To improve the performance of the abdominal muscles (obliques, rectus abdominis, transversus abdominis).

Method:-Lie on your back with your hips and knees bent and your feet flat on the floor.-If your therapist said it would help, place a pillow under your knees.-Hold your arms in front of your body.-Bring your chin towards your Adam’s apple.-Curl your trunk as far as possible.-Stop just before your hips start to bend or your feet lift off the surface.

Progression:-Perform with arms folded across chest.-Perform with hands placed on the top of the head. Do not pull on your head.

Key Concept: Contract abdominals.

Activity: Sleeping Position – Face Lying

Do: Pillows may be used to help prevent rotation sidebend or shift.

Do Not: Lie with one hip and knee flexed which results in rotating and sidebending the low back.

Key Concept: Do not lie rotated or sidebent in low back.

Lumbar Extension-RotationFunctional Activities

General Guidelines:

Your back should have a slight inward curve. Your back should be relaxed. Avoid extension, rotation and sidebending of the low back. When performing an activity, move your trunk as a unit. Avoid low back rotation, sidebending or shifting. Move your legs independently of your low back.

Activity: Rolling in Bed

Do: Contract your abdominals and slide each heel up one at a time so your hips and knees are bent. Log roll to your side. Lead with your arms (A before L).

Do Not: Rotate your lower body independently of your upper body. Extend your low back.

Key Concept: Move as a unit.

Activity: Sleeping Position – Side Lying

Do: Place a pillow between your knees. Legs should be aligned on top of each other. Place a small folded towel at your waist, just above your hip. Use a pillow to support your head.

Key Concept: Do not lie rotated or side bent in low back.

Activity: Sleeping Position – Back Lying

Do: Place 2-3 pillows under the knees so that your low back flattens. Relax your legs.

Key Concept: Do not lie rotated, sidebent or shifted in low back.

Do not rotateSupport leg

Support low back

Move knees and shoulders together

Activity: Sitting

Do: Sit with your back supported and with both feet on the floor. Relax your low back and legs. You may need a step under your feet if the chair is too high.

Do not: Sit on the edge of the chair. Sit unsupported.

Key Concept: Keep back well supported without rotation, sidebend or shift.

Activity: Sitting Position

Do: Sit with your back supported and with both feet on the floor. Relax your low back and legs. You may need a step under your feet if the chair is too high.

Do not: Sit with the low back in rotation, sidebend or shift. Cross legs.

Key Concept: Keep low back well supported without rotation, sidebend or shift.

Activity: Sit to Stand – Step 1

Do: Pull in abdominals. While keeping the back rounded, slide forward in the chair. You may use your hands on the chair to assist you.

Do not: Rotate your hips or trunk as you move to the front of the chair. Slide hips forward by pushing the upper back into the chair.

Key Concept: Do not extend back.


Do: Once at the front of the chair, position feet behind the knees. Keeping abdominals contracted stand straight up by pushing with the legs.

Do not: Extend your back as you come to standing.

Key Concept: Do not extend back.

Incorrect sitting – note shift in low back

Incorrect sitting – note rotation in low back

Activity: Sit to Stand – Limitation in Hips

Do: Push chair away from the table. Once in standing, turn away from the surface by stepping with each foot.

Do not: Rotate your trunk with your feet fixed.

Key Concept: Do not rotate trunk.

Activity: Walking

Do: Contract abdominals to control rotation of your pelvis and low back. You may slump in the low back if needed. Place your hands on your hips to monitor pelvic rotation and hike. You may choose to slow your walking speed to help control rotation.

Do not: Allow the pelvis to rotate or hike.

Key Concept: Do not rotate or hike pelvis.

Activity: Moving in Bed – Back Lying

Do: Push down with elbows and feet at the same time. Move body to side in small increments. Keep hips in line with shoulders.

Do not: Rotate, sidebend or shift in the low back.

Key Concept: Move trunk as a unit.

Activity: Moving in Bed – Side Lying

Do: To move forward, pull with hand and push into the bed with the lower leg. To move backward: push with hand and your lower leg.

Do not: Rotate, sidebend or shift in the low back.


Incorrect - note the rotation of the pelvis

Correct

Activity: Supine to Sit – Step 1 (Rolling)

Do: Contract your abdominals and slide each heel up one at a time so your hips and knees are bent. Log roll to your side. Lead with your arms (A before L).

Do not: Rotate your lower body independently of upper body. Extend your low back.


Move knees and shoulders together

Activity: Supine to Sit – Step 2 (Side Lying to Sit)

Do: From side lying, push up with your arm on the bed while letting your legs drop over the side. Keep low back rounded as you come to sitting.

Do not: Reach over with the upper hand and push into the bed. Rotate or sidebend the low back. Extend the low back.


Activity: Standing Position

Do: Pull in abdominals. Stand with feet shoulder width apart. Keep weight distributed evenly on both feet.

Do not: Stand with weight shifted on to one foot. Stand with feet crossed.

Key Concept: Contract abdominals.Incorrect standing

Correct standing

Activity: Stair Climbing - Upstairs

Do: Contract abdominals when moving your legs. Lean forward slightly to keep back rounded. You may monitor for pelvic rotation or hike with your hands. Hand rail may be used.

Do not: Rotate or hike the pelvis. Extend the low back.

Key Concept: Do not rotate or hike the pelvis.

Activity: Stair Climbing - Downstairs

Do: Contract abdominals when moving your legs. Lean forward slightly to keep back rounded. You may lean on handrail to relieve symptoms if needed.

Do not: Rotate or tilt the pelvis.

Key Concept: Do not rotate or tilt the pelvis.

Activity: Car Transfer

Do: Facing away from car, keep back straight as you sit down. Pull in your abdominals. Then with your right hand, lift one leg at a time into the car.

Do not: Rotate or extend low back.

Key Concept: Do not rotate, sidebend, or shift low back.

Correct Car Transfer

Step 1

Step 2

Lumbar RotationEducational Concepts

Activity: Driving

Do: Keep the low back supported and relaxed. Pivot on your heel to move your foot from pedal to pedal. Contract abdominals when you must lift your leg.

Do not: Lift legs if possible. Drive with one hand or lean to one side.

Key Concept: Fully support low back.

Activity: Lifting - Correct

Do: Get close to the object. Squat by flexing at the knees and hips while keeping low back rounded. Contract your abdominals. Pick up object and straighten legs to lift object.

Do not: Rotate or sidebend your low back. Extend your back.

Key Concept: Avoid lift with low back rotated or sidebent.

1. The primary contributors to your low back pain symptoms are 1. Repeated movements of your low back into sidebending,

rotation, or shift.2. Prolonged positions of your low back in sidebending, rotation,

or shift.2. The repetition of movements and positions of your low back in

sidebending, rotation or shift occurs across your day during all of your daily activities.

3. The repetition of movements and positions of your low back in sidebending, rotation or shift keeps your low back region irritated and results in low back pain symptoms.

4. The low level of irritation of tissues in your low back region that is the result of moving in the same direction all day makes it easy for your low back pain symptoms to persist or recur.

5. The emphasis of your treatment is on learning how to modify or change how you perform your daily activities so you do not rotate, side bend or shift your low back repeatedly across your day.


These changes eliminate the irritating movements and positions (rotation, sidebending or shift).

Weight shifted to one side causing sidebend in low back

Sitting with legs crossed results in shift of the low back

Correct position of the low back

Lumbar Rotation Control of Symptoms: Exercises, Activities and Positions

General Guidelines:

These activities should be performed frequently throughout the day to avoid onset or increase of your symptoms.

Minimum 4 times per day. You should not feel an increase in your symptoms with these activities. If you do, please contact your physical

therapist.

Activity: Sitting

Do: Keep back well supported without rotation, sidebend or shift. A towel may be placed behind the low back to keep the curve in the back.


Activity: Push-Up in Sitting

Movement: Sitting in a chair with hands on armrests or surface of chair. Use hands to push up and unweight the low back.

Do Not: Lean forward as you lift up.

Key Concept: Unweight low back.

Activity: Get Up Frequently

Movement: Get out of sitting position every 30 minutes and either stand or walk. You may want to set a timer to remind yourself.

Key Concept: Change load on the low back.

Activity: Relax Back Against the Wall

Do: Stand with your back to the wall using the wall as a support to unload the low back. Contract your abdominals.

Do Not: Flatten the low back. Rotate, side bend or shift the low back.

Key Concept: Relax, do not actively push back into wall.

Correct

Incorrect – note bending forward

Activity: Quadruped – Assume Position Frequently

Do: On a stable surface, get on hands and knees as shown in the picture. Hips should be positioned directly over the knees. Let the low back relax down toward the support surface.

Key Concept: Relax back down toward support surface.

Activity: Quadruped – Assume Position Frequently

Do Not: Allow the back to be in a sidebend, rotation or shift.

Key Concept: Relax back down toward support surface.

Activity: Quadruped Rock Back – Correct

Do: On a stable surface, get into hands and knees. Keeping your hands in place, rock back so your hips move over your heels. Stop before any rotation, sidebend or increase in symptoms.


Activity: Quadruped Rock Back – Incorrect

Do Not: Allow low back to flex, rotate or sidebend. Continue to rock back if symptoms get worse.


Incorrect position

Correct position – back relaxed

Correct position

Incorrect position – back is in side bend

Too much flexion

Activity: Abdominal or Back Support

Do: Apply the brace while lying down or with your back against the wall. Use as needed to control symptoms.

Key Concept: Supports low back to stop sidebending, rotating and shifting.

Activity: Side Stepping

Do: Stand with your feet shoulder width apart and your knees slightly bent.Make sure that your feet are pointing straight ahead and are in line with each other. Step straight out to the side within a comfortable step length. You may want to use a line on the floor or the wall to make sure that you do not step forwards or backwards.

Do Not: Let your pelvis drop when you step to the side. Rotate, sidebend, or shift in your spine.

Key Concept: Keep pelvis level.

Lumbar Rotation Exercises for Precision and Control of Movement


Movement: Hip and Knee Extension with Opposite Hip and Knee Maximally Flexed.

Purposes:-To stretch hip flexors. -To improve the control of the pelvis by the abdominal muscles.

Method:-Bend your hips and knees but keep your feet flat on the surface. -Place your fingers on your abdominal muscles between your pelvis and ribs at both sides of your body. -Contract abdominal muscles by pulling your navel toward your spine.

Key Concept: Keep pelvis still.


Method (cont.):

-Lift your right knee toward your chest. -Use your hands to hold your right knee close to your chest. You may need to use a towel wrapped around the thigh to assist with this motion. -Maintain the contraction of your abdominal muscles all the while you are pulling your knee up and holding it toward your chest.


Method (cont.):Make sure your abdominal muscles are contracting. -Slide your left foot away from you so that your leg straightens out and is flat on the surface. Straighten leg without letting leg turn inward or outward. To control symptoms, however, you may let the leg go out to the side slightly. -Stop immediately if you get pain in your back or if your pelvis tilts forward or rotates. Pillows can be placed under the leg being straightened to allow you to extend your leg just short of the point of symptoms. -Make sure your abdominal muscles are contracting. -Return to the starting position by sliding your left foot toward your buttocks and then by allowing your right foot to return to the table. You can dig your heel into the support surface as you slide the foot to decrease hip flexor activity. -Repeat by bringing your left knee to your chest and sliding your right foot away from you.

Progression: As you straighten your leg slide leg towards the other leg while preventing pelvic rotation and limiting symptoms.


Movement: Hip and Knee Extension from Hip and Knee Flexion.


Method:-Lie on your back with hips and knees bent and your feet flat on the floor. -Place your fingers on your abdominal muscles between your pelvis and ribs on both sides of your body. -Contract abdominal muscles by pulling your navel toward your spine.



Method (cont.):-After your leg is straightened, if you do not have pain, then slide your right (other) leg down. -Return to the starting position by first sliding one foot back toward your buttocks and then the other foot. Dig your heel into the support surface, as you slide the foot, particularly if there is an increase in symptoms. -Be sure to contract your abdominals whenever you are moving your legs.-If your therapist said it would help, place a pillow under your upper back and head. -If the person is unable to perform a leg slide without symptoms, position a pillow under one knee and perform hip and knee extension with the opposite leg.-In this case, perform all repetitions with one leg before performing with the opposite leg.










Method:-Lie on your back with your hands on your pelvis. -Bend your left knee and hip but keep your foot on the surface.-Keep your right knee straight.



Method (cont.):-Contract your abdominals by pulling your navel toward your spine.-Let your left knee move out to the side (away from your trunk).


Method (cont.):-With your left leg out to the side, pick up your foot and straighten your knee. -Do not push down with your right (non-moving) leg.-Do not let your pelvis rotate.-Hold your knee straight for a few seconds, then bend your knee again and let your foot rest on the surface.-Bring your left knee back to the upright position.-Straighten your left hip and knee.-Repeat the entire sequence with your right (other) leg.








Method (cont.):-Contract your abdominals by pulling your navel toward your spine.-Let your left knee move out the side (away from your trunk).


Method (cont.):-Do not let your pelvis move while you are moving your left leg. -Perform all repetitions with one leg and then repeat with the other leg.




Method:-Lie on your back with your hands on your pelvis. -Bend your left knee and hip but keep your foot on the surface.-Keep your right knee straight.-Contract your abdominals by pulling your navel toward your spine.-Let your left knee move out to the side (away from your trunk).-With your left leg out to the side, pick up your foot and straighten your knee.-After straightening your knee, move your leg toward your right (opposite) shoulder by moving at your hip.-Do not let your pelvis move while you are moving your leg.-Move your leg back away from your right (opposite) side and back out to the left.-Bend your left knee and let your foot rest on the surface.-Bring your left knee back to the upright starting position.-Straighten your left hip and knee so that your entire leg is flat on the surface.-Repeat the entire sequence beginning with your right (other) leg.


Exercise: Side Lying – Hip Lateral Rotation

Movement: Hip Lateral Rotation in Side Lying

Purposes:-To improve the performance of the hip lateral rotator muscles.-To be able to move the hip without moving the pelvis.-To improve the isometric performance of the lateral abdominal muscles.

Method:-Lie on your right side with your right (bottom) hip and knee bent.-Rotate the left side of your pelvis slightly forward (toward the surface).-Let your left (top) hip and knee bend to 45 degrees and rest on your right (bottom) leg with a pillow between your knees.-Also place a small towel with a few folds under the waist to reduce symptoms and keep back level.


Exercise: Side Lying – Hip Lateral Rotation – Step 2

Method (cont.):-Place your left hand on your pelvis.-Rotate your left leg so that your knee turns upward.-Move in your left hip joint only.

Exercise: Side Lying – Hip Lateral Rotation – Step 3

Method (cont.):-Rotate your left leg upward as far as possible.-Do not let your pelvis or trunk move backward.

Progression: Perform the same movement with hip and knee less bent.

Exercise: Hip Lateral and Medial Rotation in Face Lying – Step 1

Movement: Hip Lateral and Medial Rotation in Face Lying

Purposes:-To decrease the compensatory motion of the lumbopelvic region during hip motion.-To improve the flexibility and stretch the hip rotator muscles.-To improve the performance of the abdominal muscles.

Method:-Lie face down with your legs straight and relatively close together.-Bend your left knee to 90 degrees.-If your therapist said it would help, place a pillow under your abdomen.



Method (cont.):-If your therapist said it would help, place your hands on your buttocks or on the front of your pelvis so you can tell if your pelvis is moving.-Contract your abdominal muscles by pulling your navel toward your spine.-Bend your left knee to 90 degrees.


Method (cont.):-Rotate your hip by allowing your left foot to move in toward the right (other) leg.-Do not let your pelvis move.


Method (cont.):-Rotate your hip by allowing your left foot to move away from your right (other) leg.-Do not let your pelvis move.-Return to the starting position.

Perform all repetitions with one leg and then repeat with the other leg.

Exercise: Arm Lifts in Quadruped

Movement: Shoulder Flexion in Quadruped

Purposes:-To improve the performance of the abdominal muscles.-To improve the control of the spine in preventing rotation.-To improve balance control.

Method:-Get on your hands and knees.-Place your knees 4 – 6 inches (10 – 15 cm) apart.-Center your hips over your knees.-Bend your hips to 90 degrees.-Point your toes.-Center your shoulders over your hands.-Keep your head in line with your body.-Contract your abdominal muscles by pulling your navel toward your spine.-You can also push down and back with the hand of the stationary arm to prevent movement in the trunk.

Options:-Barely lift your left hand off the supporting surface by bending your elbow.-Rock back slightly so that the hips are bent past 90 degrees.-Lift your left arm overhead so it is parallel with the support surface.

-Do not let your trunk move or shift when lifting the arm.-Return your left hand to supporting surface.


Key Concept: Do not let the trunk move.

Exercise: Single-Leg Standing

Movement: Unilateral Hip and Knee Flexion in Standing

Purposes:-To improve the performance of the gluteal hip muscles.-To improve the isometric performance of the lateral abdominal muscles.-To prevent compensatory movements of the hip, pelvis, and spine.-To prevent the thigh from turning inward.

Method:-Stand with your feet close together so you do not shift too far.-Use a table or chair for support / balance as needed.-Shift your weight with your left foot.-Tighten the muscles in your left trunk to prevent your pelvis from tilting or rotating.-Lift your right thigh upward in front of your body (no farther than 90 degrees).-Bend your right knee as you lift your thigh upward.-Repeat the entire sequence with your other leg.

If unable to perform correctly or without pain, can make easier by not lifting leg. Weight shift from side to side using the same cues to tighten trunk muscles. Do not let the pelvis move.

Key Concept: Keep pelvis level. Do not lean your trunk to one side.


Movement: Lateral Spine Flexion

Purpose:-To increase the flexibility of the paraspinal muscles.-To increase the flexibility of the abdominals.-To decrease the excessive flexibility of some spinal segments.

Method:-Stand with both feet comfortably apart.-Place your hand at the lowest level of your ribcage and above your pelvis to assist motion and prevent any shifting or translation of the lower back. If your therapist instructs you to, you may raise your arms overhead and clasp your hands together (as in picture) to provide an additional stretch on the side of your trunk.

Key Concept: Move in upper trunk not low back.


Method (cont.):-Stand with your back against a wall to avoid rotating your body.


Method (cont.):-TILT your shoulders to the left side.-Think about bending in the area of your chest rather than your waist.-Stop if you feel pain.-If your therapist said it would help, place your hand on your left side at waist level, between the top of your pelvis and the bottom of your ribs (as in picture).-Lean to your left side.-Return to the starting position.-Repeat to the right (other) side.

Perform all repetitions to one side before performing repetitions to the other side.

Exercise: Relax Back Against Wall

Purposes:-To relax the low back.

Method:-Stand with your back against a wall.-Place your heels about 3 – 6 inches (8 – 15 cm) away from the wall.-Bend your knees and hips enough that you can flatten your low back against the wall.-Make sure your low back is flat even if it means your upper back and shoulders are leaning forward.-Relax.

Key Concept: Relax, do not actively push back to the wall.

Exercise: Sitting Knee Extension – Step 2

Method:-Straighten your left knee as far as possible while contracting your abdominal muscles to prevent your pelvis from rotating.-Do not let your back move while you are straightening your knee.-If your therapist said it would help, push your upper back into the chair.

Exercise: Sitting Knee Extension – Step 1

Purpose: -To improve the length of the hamstring muscles.-To improve the control of the back extensor muscles.-To decrease the tendency for the back to bend outward.-To control undesirable hip rotation during knee movement.-To stretch the calf muscles.-To improve the control by the muscles that lift the ankle.

Method:- Sit on a straight back chair.-Your hips should be at a right angle to your trunk and your shoulders should be in line with your hips.-You may rest both feet on the floor.-Place hands on your low back to make sure your back and pelvis do not move.


Movement: Shoulder Adduction while Maintaining Contraction of Abdominal Muscles

Purposes:-To improve the performance of the abdominal muscles.

Method:-Lie on your back with your hips and knees bent, so that your feet are flat on the surface and your arms are at your sides.-See second picture.-Grasp the weight your therapist told you to use.-Slide your left arm out to the side far enough that your hand is slightly above your head (see Figure).-Contract your abdominal muscles by pulling your navel toward your spine.

Key Concept: Do not let trunk rotate.


Method (cont.):-Lift your left arm toward the ceiling and toward your right (opposite) hip. -Keep your elbow straight.-Stop moving your arm when it is pointing straight up toward the ceiling.-Return your arm to the surface.


Can progress the exercise by performing the same motion in standing.

Exercise: Lower Abdominal Progression – Pre-Level 1

Movement: Hip and Knee Flexion with Opposite Leg Held toward Chest

Purposes:-To improve the isometric performance of the abdominal muscles (obliques, rectus abdominis, transversus abdominis).-To move the lower extremity without movement of the pelvis or spine.

Method:-Bend your hips and knees but keep your feet flat on the floor.-Contract your abdominal muscles by pulling your navel toward your spine.



Method (cont.):-Lift your right knee toward your chest. -Hold your knee toward your chest with your hands.-If you are able to hold your knee with one hand, place your other hand on the abdominal muscles between your pelvis and ribs at the side of your body.-Be sure the abdominal muscles are contracted.-Lift your left (other) foot off the surface to 90 degrees.


Method (cont.):-Keep your back from moving while you lift your leg.-Lower your left foot to the surface.-Keep your back from moving while you lower your leg.-Lower your right (other) foot to return to the starting position.-Repeat the entire sequence beginning with your left (other) leg.

Exercise: Lower Abdominal Progression – Level 1A

Movement: Hip and Knee Flexion with other Hip Flexed to >90 Degrees

Purposes:-To improve the performance of the abdominal muscles (obliques, rectus abdominis, transversus abdominis).-To move the lower limb without movement of the pelvis or spine.

Method:-Bend your hips and knees but keep your feet flat on the floor.-Place your fingers on your abdominal muscles between your pelvis and ribs at both sides of your body.-Contract your abdominal muscles by pulling your navel toward your spine.



Method (cont.):-Lift your right foot off the surface and bring your right knee toward your chest so that your hip is flexed more than 90 degrees.


Method (cont.):-If necessary, contract your abdominal muscles again.-Lift your left foot off the surface.-Keep your back from moving while you are lifting your legs.-Do not let your chest depress.-Do not let your abdomen distend.


Method (cont.):-While maintaining the contraction of your abdominal muscles, lower your left foot to the surface (the foot you just lifted).-Lower your right (other) foot to return to the starting position.-Repeat the entire sequence beginning with your left (other) leg.

Exercise: Lower Abdominal Progression – Level 1B

Movement: Hip and Knee Flexion with Other Hip Flexed to 90 Degrees

Method:-Bend your hips and knees but keep your feet flat on the floor.-Place your fingers on your abdominal muscles between your pelvis and ribs at both sides of your body.



Method (cont.):-Contract your abdominal muscles by pulling your navel toward your spine. -Lift your right foot off the surface and bring your knee toward your chest so that your hip is flexed to 90 degrees.-If necessary, contract your abdominal muscles again.-Lift your left (other) foot off the surface.-Keep your back from moving while you are lifting your leg.


Method (cont.):-Do not let your chest depress.-Do not let your abdomen distend.-While maintaining the contraction of your abdominal muscles, lower your left foot to the surface (the foot you just lifted).-Lower your right (other) foot to return to the starting position.-Repeat the entire sequence beginning with your left (other) leg.

Exercise: Lower Abdominal Progression – Level 2

Movement: Hip and Knee Flexion with Foot Partially Supported





Method (cont.):-Contract your abdominal muscles by pulling your navel toward your spine.-Lift your right leg up until your hip is bent to 90 degrees and your thigh is pointing toward the ceiling. -Keep your back from moving while you are lifting your leg.-Do not push down with your left (other) foot.-Do not let your chest depress.


Method (cont.):-If necessary, contract your abdominal muscles again.-Do not let your abdomen distend.-Do not push your head back into supporting surface.-Do not hold your breath.-Lift your left (other) foot so that it is only lightly touching the surface.-Slide your left foot away from you until your leg straightens completely.


Method (cont.):-Contract your abdominal muscles again.-Slide your left foot back to the starting position.-Lower your right (other) foot down to the surface, so that both feet are on the surface again.-Repeat the entire sequence beginning with your left (other) leg.


Movement: Hip and Knee Extension with Foot Unsupported


Method:-Lie on your back with your hips and knees bent and your feet flat on the surface.-Place your fingers on your abdominal muscles between your pelvis and ribs at both sides of your body.



Method (cont.):-Contract your abdominal muscles by pulling your navel toward your spine.-Lift your right leg up until your hip is bent to 90 degrees and your thigh is pointing toward the ceiling. -Keep your back from moving while you are lifting your leg.-Do not let your chest depress.


Method (cont.):-Do not let your abdomen distend.-Do not push your head back into supporting surface.-Do not hold your breath.-If necessary, contract your abdominal muscles again.-Lift your left (other) foot so that it is not touching the surface.-Straighten your left hip and knee completely.


Method (cont.):-Lower your left leg to the supporting surface. Rest the leg for a count of 3.-Contract your abdominal muscles again.-Lift your left foot again and move it back to the starting position.-Lower your right (other) foot down to the surface, so that both feet are on the surface again.-Repeat the entire sequence beginning with your left (other) leg.

Exercise: Side Lying - Hip Abduction

Movement: Hip Abduction

Purposes: -To improve the performance of the hip abductor muscles.-To improve the isometric performance of the lateral abdominal muscles.-To move in the hip joint without movement in the pelvis.

Method:-Lie on your right side with your right (bottom) hip and knee bent to about 60 degrees.-Place a small towel with a few folds under the waist to keep the lumbar region level.-Straighten your left (top) hip and knee and place your leg in line with your body.-Rotate the left side of your pelvis slightly forward (toward the surface).-Place your left hand on your pelvis or on the gluteus medium area of your buttock muscles.



Method (cont.):-Slightly rotate left top leg so your knee is pointing slightly upward.-Contract abdominal muscles.


Method (cont.):-Keep your left hip straight and lift your leg toward the ceiling.-Do not let your pelvis move or allow your back to arch while lifting your left leg.-Lower your left leg toward the surface without letting your pelvis move.-If your left leg does not lower at least 15 degrees below the level of your left hip, try to let your hip muscles relax and let your leg fall lower.-Do not let your knee turn inward.-Do not let your pelvis move.-Relax and return to the starting position.-Repeat the entire sequence with your right (other) leg after you position yourself on your left side.


Movement: Knee Flexion in Prone

Purposes:-To decrease the compensatory motion of the pelvis and spine.-To increase the flexibility and stretch the quadriceps and tensor fascia latae muscles.-To improve the performance of the abdominal muscles.

Method:-Lie face down with your legs straight and relatively close together.-If your therapist said it would help, place a pillow under your abdomen.



Method (cont.):-Place your hands on your buttocks or on the front of your pelvis so you can tell if the pelvis is moving.-Contract your abdominal muscles by pulling your navel toward your spine.-Bend your left knee.-Do not let your pelvis or low back rotate or tilt forward.-Do not pull so hard that you get a cramp in the back of your thigh.-Return your leg to the starting position.-Repeat the entire sequence beginning with your right (other) leg.

Exercise: Leg Lifts with Knee Extending in Face Lying

Movement: Hip Extension with Knee Extended in Face Lying

Purposes:-To improve the performance of the gluteus maximus and the hamstrings.-To stretch the hip flexors-To improve the performance of the back extensor muscles.-To improve the performance of the abdominal muscles.

Method:-Lie face down with your legs straight and relatively close together.-If your therapist said it would help, place a pillow under your abdomen.-Place your hands on your buttocks or on the front of your pelvis so you can tell if the pelvis is moving.-Contract your abdominal muscles by pulling your navel toward your spine.-Turn your left leg slightly outward as you contract your buttock muscles and lift your entire leg off the supporting surface.-Do not let your pelvis move.-Do not lift your leg too high; there are only 10 degrees of hip motion in this direction.-Hold for count of 3 – 10 seconds.-Return your leg to the starting position.-Repeat with your right (other) leg.

Activity: Sleeping – Face Lying

Do: Pillows may be used to help prevent rotation, side bend or shift.

Do Not: Lie with one hip and knee flexed which results in rotation and sidebending in the low back.

Key Concept: Do not lie with trunk rotated, sidebent or shifted.

Lumbar Rotation Functional Activities

General Guidelines:

Your low back should be slightly curved. When performing an activity, move your trunk as a unit. Avoid trunk rotation, sidebending or shifting. Move your legs independently of your back.

Activity: Rolling in Bed

Do: Contract abdominals and slide each heel up one at a time so your hips and knees are bent. You may use your feet to push into the surface to log roll to your side. Lead with your arms (A before L). To return to back lying, push with your hand and lower leg.

Do Not: Rotate your lower body independently of upper body.

Key Concept: Move as a unit.

Activity: Sleeping – Side Lying

Do: Place a pillow between your knees. Legs should be aligned on top of each other. Place a small folded towel at your waist, just above your hip. Place pillow to support your head.


Activity: Sleeping – Back Lying

Do: Pillows may be placed under the knees to relieve pressure on the low back. Keep back straight.


Do not rotateSupport leg

Support low back

Activity: Moving in Bed – Back Lying

Do: Push down with elbows and feet at the same time. Move body to side in small increments. Keep hips in line with shoulders.

Do Not: Rotate or shift in the low back.


Activity: Moving in Bed – Side Lying

Do: To move forward: pull with hand and push into the bed with the lower leg. To move backward: push with hand and your lower leg.

Do Not: Rotate or shift in the low back.


Activity: Supine to Sit – Step 1 (Rolling)

Do: Contract abdominals and slide each heel up one at a time so your hips and knees are bent. You may use your feet to push into the surface to roll trunk as a unit to your side. Lead with your arms (A before L).

Do Not: Rotate your lower body independently of upper body.


Activity: Supine to Sit – Step 2 (Side Lying to Sit)

Do: From side lying, push up with your arm that is on the bed while letting your legs drop over the side. Keep low back straight as you come to sitting.

Do Not: Reach over with the upper arm and push into the bed. Rotate or sidebend the low back.


Correct

Incorrect – hips are not in line with shoulders

Activity: Sitting

Do: Sit with both feet on the floor.

Do not: Sit with the low back in rotation, side bend or shift. Cross legs. Sit unsupported.

Key Concept: Keep back well supported without rotation, sidebend or shift.

Activity: Sitting

Do: Have support behind the low back.

Do not: Sit with the low back flexed or in rotation, sidebending or shift. Cross legs.

Key Concept: Keep back well supported; do not rotate, side bend or shift low back.

Activity: Sitting at Desk - Moving

Do: When turning, be sure to turn the chair not your low back.

Do Not: Rotate in the low back to turn. Reach to the side that may result in a sidebend or a shift of the low back.

Key Concept: Keep back well supported; do not rotate, sidebend or shift low back.

Correct – Back supported

Incorrect – Back not supported

Incorrect – Legs crossed

Incorrect – Note side bend in back


Do: Slide forward in the chair. You may use your hands on the chair to assist you.

Do Not: Rotate your hips or trunk as you move to the front of the chair.

Key Concept: Do not rotate hips/trunk from side to side as you move forward in chair.


Do: Once at the front of the chair, lean forward at the hips keeping the back straight.

Do Not: Rotate, side bend, or shift your low back as you come to standing.

Key Concept: Do not rotate hips/trunk from side to side as you move forward in chair.

Activity: Sit to Stand and Turn – Limitation in Hips

Do: Push chair away from the table. Once in standing, turn away from the surface by stepping with each foot.

Do Not: Rotate your trunk with your feet fixed.

Key Concept: Do not rotate trunk.

Activity: Walking

Do: Contract abdominals to control rotation of your pelvis and low back. Place your hands on your hips to monitor pelvic rotation. You may choose to slow your walking speed to help control rotation.

Do not: Allow the pelvis to rotate.

Key Concept: Do not rotate or hike the pelvis.

Activity: Standing Position

Do: Keep weight distributed evenly over both feet.

Do not: Stand with weight shifted on to one foot. Stand with feet crossed.

Key Concept: Feet shoulder width apart.

Activity: Stair Climbing - Upstairs

Do: Contract abdominals when moving legs. You may monitor for pelvic rotation or hike with your hands. Hand rail may be used.

Do not: Rotate or hike the pelvis.

Key Concept: Do not rotate or hike pelvis.

Activity: Stair Climbing - Downstairs

Do: Contract abdominals when moving legs. You may monitor for pelvic rotation or tilt with your hands. Hand rail may be used.

Do not: Rotate or tilt the pelvis.

Key Concept: Do not rotate or tilt pelvis.

Incorrect standing

Correct standing

Incorrect - note the rotation of the pelvis

Correct

Incorrect stair climbing

Correct stair climbing

Incorrect stair climbing

Correct stair climbing

Activity: Car Transfer

Do: Facing away from the car – keep back straight as you sit down. Then with your right hand, lift one leg at a time into the car.

Do not: Rotate or flex low back.

Key Concept: Do not rotate, sidebend or shift low back.

Activity: Driving

Do: Back should be well supported.

Do not: Lean forward. Lean to one side. Rotate or sidebend the low back.


Activity: Lifting - Correct

Do: Get close to the object. Squat by flexing at the knees and hips while keeping back straight. Contract your abdominals. Pick up object and straighten legs to lift object.

Do not: Rotate or sidebend your low back.

Key Concept: Squat; move trunk as a unit.

Activity: Lifting - Incorrect

Do not: Rotate or sidebend in the low back.

Key Concept: Squat; move trunk as a unit.

Activity: Driving

Do: Keep the low back supported and relaxed. Pivot on your heel to move your foot from pedal to pedal. Contract abdominals when you must lift your leg.

Do not: Lift legs if possible. Drive with one hand or lean to one side.


Correct Car Transfer

Step 1

Step 2

Non Classification-Specific Condition

Educational Concepts

1. A balanced spine position is one in which the normal curves of the spine are maintained (the lower back has a slight curve forward and the upper back has a slight curve backward).

2. Low back pain symptoms can be the result of several contributors that include poor posture, faulty body mechanics, stressful living and working habits, loss of flexibility, and decline of general fitness.

3. General exercise and maintaining my activity level are both important for coping with low back pain symptoms.

4. Exercise is beneficial because it increases bone strength, makes muscles fit, increases flexibility, makes me feel goodIt contributes to release of natural chemicals that reduce symptoms

5. Muscle soreness after exercise is expected with the performance of new exercises.


Strength and Flexibility Exercises: Trunk Flexibility – Phase 1

Activity: Lower Back Flexion

Movement: Lie on the floor or bed, drawing your knees up to your chest. Grip your knees and pull them into your chest.

Key Concept: Stretch in the low back.

Activity: Trunk Rotation in Supine with Hips and Knees Flexed

Position: Lying on your back with knees together and bent.

Movement: Slowly roll your knees from side to side keeping your upper trunk still. Perform on one side first, then repeat on the other side.

Key Concept: Stretch waist/low back.

Activity: Trunk Flexion/Extension in Hands and Knees

Position: Assume hands and knees position with your hands under your shoulders.

Movement: Let low back sag toward floor as you rotate tailbone and head upward; arch back as shown. Now lower your head and make a “hunch back”, tucking your tail bone under as shown.

Key Concept: Stretch trunk.

Activity: Trunk Extension in Prone

Position: Lying face down keeping elbows/forearms at 90 degree angle as in picture.

Movement: Arch the small of your back by pressing your pelvis and stomach to the floor. Now bend your upper back upwards, keeping forearms on the floor.

Key Concept: Stretch into extension.

Activity: Sidebending in Standing

Position: Stand with feet shoulder width apart.

Movement: Bend sideways at the waist keeping your body from bending forwards, bending backwards, or twisting.

Key Concept: Stretch side of trunk.

Strength and Flexibility Exercises: Trunk Flexibility Alternative Exercises– Phase 1

Activity: Trunk Extension in Prone - Alternative

Position: Lying face down.

Key Concept: None.

Activity: Trunk Flexion/Extension in Standing with Upper Extremity Support

Position: Stand with knees bent slightly, upper body inclined forward with hands resting on a support surface such as a table our countertop, back neutral as shown.

Movement: Tighten abdominal muscles, squeeze buttock muscles and flatten back as shown.

Key Concept: Stretch trunk.

Strength and Flexibility Exercises: Extremity Flexibility – Phase 1

Activity: Hamstring Stretch (Active Knee Extension)

Position: Lie on the floor or the bed, flex your hip 90 degrees.

Movement: Grip your hands behind the knee and actively straighten the knee using the muscles in the front of your thigh and bend foot towards you. You can use a towel behind your knee to assist holding the leg.

Key Concept: Stretch in back of thigh.

Activity: Gluteal/Hip Flexor Stretch

Position: Lying on your back.

Movement: Bend the leg to be stretched towards your chest and hold onto the knee with both hands. Pull your knee towards your chin keeping your head on the floor. Keep the opposite leg straight. You should feel the stretching on the back of your thighs and buttock. You may also feel a stretch in the front of your thigh on the opposite leg.

Key Concept: Stretch buttock muscle.

Activity: Quadriceps Stretch

Position: Stand facing wall with your hands supporting your body weight.

Movement: Flex your right leg, and grip your ankle with your knee flexed. Pull the leg back while maintaining correct spinal alignment.

Key Concept: Stretch front thigh muscle.

Activity: Calf Stretch

Position: Position your body against a wall as shown with one foot behind you.

Movement: Point toes directly towards the wall and hold heel down. Lean into wall as shown so that you feel a stretch.

Key Concept: Stretch calf.

Activity: Piriformis Stretch

Position: Lie on back holding knee and ankle as shown.

Movement: Hold knee stable as you pull ankle toward your chest so that you feel a stretch.

Key Concept: Stretch hip muscle.

Strength and Flexibility Exercises: Extremity Flexibility Alternate Exercises – Phase 1

Activity: Alternate Gluteal Stretch

Movement: Hold underneath thigh and bring knee towards chest. Keep tall. Head up.

Key Concept: Stretch buttock muscle.

Activity: Hamstring Stretch – Alternative #1

Position: Lie on back with leg propped in doorway as shown.

Movement: Keep the opposite leg straight on the floor. Lie as close to the base of the doorway as possible, while keeping the legs straight.

Key Concept: Stretch back of thigh.

Activity: Hamstring Stretch – Alternative #2

Position: Sit with leg propped as shown.

Movement: Relax, letting the leg straighten. Lean forward, keeping the back straight and pull toes toward you.

Key Concept: Stretch back of thigh.

Activity: Quadriceps Stretch – Alternative #1

Position: Lie on surface as shown.

Movement: Hold on to your ankle and bend the knee so that you feel a stretch. You may use a towel to assist the motion.


Activity: Piriformis Stretch – Alternative

Position: Sitting on a chair with your foot on the opposite knee

Movement: Lean forward and gently push your knee towards the floor.

Key Concept: Stretch hip muscle.

Strength and Flexibility Exercises: Extremity Flexibility Alternate Exercises – Phase 1 (cont.)

Activity: Quadriceps Stretch – Alternative #2

Position: Stand straight with one knee bent and the foot supported on a stool as in the picture.

Movement: Hold on to something secure and lean backward, stretching the muscle in the front of your thigh.


Activity: Calf Stretch - Alternative

Position: Sit with one leg straight out in front of you. Put a towel or sheet around your foot.

Movement: Gently pull the towel/sheet and feel the stretch in your calf.

Key Concept: Stretch calf.

Activity: Single Arm Lift in Prone

Position: Lie on belly with one arm overhead and your other arm by your side.

Movement: Place a towel under your forehead. Raise arm upward.

Key Concept: Strengthen low back.

Activity: Bridging

Position: Lie on back with knees bent.

Movement: Squeeze your buttocks together and lift your bottom off the floor. Return to starting position.


Activity: Posterior Pelvic Tilt

Position: Lie on back with knees bent. You can put your hands on your stomach.

Movement: Tighten abdominal muscles, squeeze buttock muscles and flatten back as shown.

Key Concept: Strengthen abdominals.

Activity: Trunk Extended in Prone – Arms Extended

Position: Start lying face down with both your hands at shoulder height.

Strength and Flexibility Exercises: Trunk Strength – Phase 1

Strength and Flexibility Exercises: Progression – Phase 2

Activity: Trunk Extended in Prone – Arms Extended

Position: Start lying face down with both your hands at shoulder height.

Activity: Opposite Arm and Leg Lift in Prone

Position: Lie on belly with 2 inch towel roll under forehead and a pillow under your chest if necessary.

Movement: Tighten buttocks together and raise one leg and opposite arm as shown.


Activity: Bridging with Resistance

Position: Lying on your back with knees bent.

Movement: Place a theraband across your hips/pelvis and hold the band to the floor with your hands. Squeeze your buttocks together and lift your bottom off the floor. Return slowly to starting position.


Activity: Abdominal Crunch

Position: Lying on your back with arms crossed on your chest.

Movement: Tighten your stomach muscles and lift your head and shoulders off the floor. Keep your chin tucked in.

Key Concept: Strengthen abdominals.

Activity: Active Trunk Extension

Position: Lying face down with your arms by your side with a towel roll under your forehead.

Movement: Lift your upper trunk while looking at the floor.


Activity: Abdominal Crunch with Rotation – Arms by Side

Position: Lying on your back with arms crossed on your chest.

Movement: Reach toward knees, raise head and shoulders, and curl trunk upward and to the side as shown. Alternate sides.

Key Concept: Strengthen obliques.

Strength and Flexibility Exercises: Progression – Phase 3

Activity: Active Trunk Extension

Position: Lying face down with your arms by your side with a towel roll under your forehead.

Movement: Lift your upper trunk while looking at the floor.


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