Manual of 'Practical' Physical Therapy

Michael D. Burgos Fitzgerald G. Onate Irving Christian Dy Mancao

C & E Publishing Incorporated Aurora Arcade, No. 41 Aurora Blvd., Quezon City Philippines

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102

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Exercise is medicine, and was considered the best prescription!" ote: Exercise, like medicine, has also 'side effects' (i.e., negative -"ffects!) if done excessively, improperly, and most of all, if appropriately! That's why" it has to be individualized on a 'case-toase' basis!" While there's no universal medicine for a certain disease ith different variants, it also holds true that no exercise is a panacea 'Or a certain disease or physical complaint/problem with different linical presentations. Thus, it has to be a 'rational' (i.e., based on ~nderstanding of the cause and mechanisms of a specific disease and the potential effects of the procedures.) and 'individualize' reatment program. Remember! These exercises are not intended as a substitute for medical treatment. Before starting a rehabilitation program, consult a physician. "Comparison Between Exercise Therapy and Drug Therapy" Parameter: Type Exercise: Drugs: > Aerobic, anaerobic, > Antibiotics, analgesics, stretch, relaxation, anti-inflammatories, flexibility,coordination, sedatives, antidepressants hormones. toning.

[1

I' ,

Frequency

> 1-3 times/day,

7 days/week

> 1-3 times/day, 7 days/week

Duration Time of day Contraindications

> Lifetime > Various

- > Short-term or lifetime

> Various

> Illness, pain

> Allergy, rash, polypharmacy, other diseases.

Xlll

.:..~e.anemIa, _~_-:.a~symptoms,

> Required

> \f;::!nable

> Variable

TABLE OF CONTENTS

_~USCULOSKELETAL/ORTHOPEDIC

CASES

6. 7. 8.

9. 10. 11.

12.

13. 14, 15,

Strength and stretch program for De Quervain's syndrome Exercise program to recover from shoulder pain (and. other dysfunction from rotator cuff problems, subdeltoid bursitis, etc.) A simple cure,-exercise program and home exercises-for tennis and golfer's elbow. Exercise program for hand injuries (eg. post-burn edema ), with hand muscle pumping exercises for edema reduction. Postural exercises using the recommended stretching exercise program (for spinal pain patients and other related dysfunction), and the basic postural exercises (for "Ambulatory" Patients", especially with RA.) Exercise for flatfoot. Exercise for metatarsal arch disturbances (fallen arches) Exercise program for TMJ dysfunction. (as an alternative to splint therapy: using the six-by-six program, lower jaw thrust, and 'chewing the pencil' exercise). Muscle energy therapy for acute wryneck (torticollis) Exercises for dysfunctional neck (i.e., tenderne~s and stiffness) following injury (acute and chronic), with home program. Thoracic spinal manipulation for upper to lower thoracic dysfunction {from excessive overhead activities, lifting, whiplash injury, etc.) using "Nelson Hold" (for upper to midthoracic dysfunction), Indirect Postero-Anterior Thrust (for T3 to T8), and Thigh Extension Thrust Techniqu,e (for upper thoracic dysfunction.) Thoracolumbar manipulation for unilateral pain at the thoracolumbar junction or for pain (unilat. or bilat.) of the lumbar and lower thoracic spine. Rotation mobilization for lumbar spine (Acute LBP). Lumbar non-specific rotation (or "Million Dollar Roll ") for non-specific lumbar complaints. Treatment of snapping or clicking hip (using exercise program)
XlX

16. 17. 18.

19.

20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

Treatment and prevention of muscle cramp (with pre\treatment of leg nocturnal cramp) Strengthening and stretching exercises that can be use, work hardening or work conditioning program. Mediolateral gliding mobilization of subtalar joint for cI post-traumatic ankle stiffness, with or without pain, sprained ankle. Treatment of vertebral compression fracture seconda: osteoporosis (with osteoporosis exercise and other exte exercises). Hip arthroplasty home exercise program and general instruction. Home instruction and exercise program for total replacement (TKR) "Strain and counterstrain" treatment approach for fr shoulder. Treatment of restless leg syndrome (or Ekbom's syndro .. usmg exerCIse programs. Treatment of mallet finger (using taping technique) Simple reduction of dislocated finger. Reduction of pulled elbow Reduction of dislocated shoulder (using free-hanging meth and of recurrent dislocation of the shoulder. Reduction of dislocated elbow (uncomplicated poste dislocation) Reduction of dislocated jaw.

NEURO 30. Nerve gliding exercises to facilitate proper gliding of . median nerve in the carpal tunnel, and manipulation "carpal tunnel syndrome" ("Million Dollar Syndrome") Home exercise program, Flewitt-Handford Exercise (l Parkinson's gatt), and Schenkman's treatment approach f . Parkinson's disease. Home treatment, and retraining specific action exercise (SAJ for eye closure ('Lagopthalmos') in Bell's palsy. Manual traction to the neck for treating nerve root irritatic with arm pain, and acute neck pain with headache. xx

31.

32. 33.

Manual traction for sciatica Treatment of provoked vertigo (especially BPPV) and intolerance to movement using Cawthorne-Cooksey Exercise, and Vestibular Habituation Training (with Alternative Vestibular Habituation Exercise: "PT for BPPV" .) ARDIOPULMONARY Post- Thoracotomy Exercise at home 7. Breathing exercise for COPD and other thoracic condition that impairs breathing (with home exercise program). 8. Cardiopulmonary PT treatment for inability to meet physical demands of ADL, using energy saving/work simplification techniques GENITO-URINARY 39. Treatment of stress urinary incontinence, using Kegel exercise (or pelvic floor muscle exercises) OB-GYNE 40. Postpartum exercises.

XXI

EXERCISE

FOR De QUERV AIN'S SYNDROME

De Quervain' s disease is a stenosing tenosynovitis of the uctor pollicis longus or extensor pollicis brevis tendons over the _ial styloid of the wrist, or both. It results from repetitive activity, __;:h as that engaged in by staple gun operators on assembly lines, or m direct trauma.

Symptoms
The major symptoms are: a.) Pain during pinch grasping. b.) Pain on thumb and wrist movement.

Triad of diagnostic signs

Three key diagnostic signs are: 1.) Tenderness to palpation over and just proximal to the radial styloid; 2.) Localized swelling in the area of the radial styloid; 3.) Positive Finkelstein's sign. Strength and stretch program for De Quervain's muscle weakness and adhesions) Syndrome2 (i.e., for its

I Murtagh, J.: Practice Tips, Singapore, McGraw-Hill Book Company, p. : Key, G.L.: Industrial Therapy. ed. I, Mosby-Yearbook. Inc .. p. 207
1

III

. Exercisesfor

de Quervain's Tenosynovitis

..- . .."..

rist Radial/Ulnar (!l,;ation: Active ROM.

b.) Wrist Radial/Ulnar deviation: Active ROM against gravity.

Active resistive: Radial deviation.

d.) Active resistive: Ulnar deviation.

EXERCISES DESIGNED TO RECOVER FROM SHOULDER DYSFUNCTION (i.e. PAIN, STIFFNESS, etc.) STRENGTHENING EXERCISES FOR THE ROTATOR CUFF MUSCLES AND OTHER SHOULDER MUSCLES AFTER SUPRASPINATUS TENDINITIS, OR "SWIMMER'S SHOULDER,,)3 Begin a rotator cuff strength and endurance program as soon as you can do the exercises without pain. Because swimmers take thousands of strokes per session, repetitions are more important than weights in rehabilitation. Swimmers injure the supraspinatus more than any rotator cuff muscle, so the thumbsdown supraspinatus exercise (Fig. 2-1 a) is a good gauge of the shoulder's health. A swimmer with a healthy shoulder should be able to do it 50 times without weights. This and other strengthening exercises can be done at home, at school, in the office, or at pool side. The exercise shown in Fig. 2-1 a to Fig. 2-1 d requires elastic exercise bands. Avoid taking anti-inflammatory drugs like aspirin or ibuprofen before doing the strengthening exercises because they can mask the pain. As you build strength, you can try gradually returning to more intense swimming. NOTE: As you increase your effort, let pain be your guide: Ease up if your shoulder starts to hurt again, and stop if the pain persists. Remember: This exercise is not intended as a substitute for a medical treatment. Before starting a rehabilitation program, consult a physic~~n.

Loosli, A. R., and Quick, I.: Recovering from shoulder pain (Tips for swimmers,) The Physician and Sports Medicine journal, February 1996; 24(2)33-34

.. 1a. To work your 'spinatus (one of the or cuff muscles), stand your arms at your sides. thumbs pointing down, both arms out at your about 45forward '5e your arms as high as allows, but keep them shoulder level, and d shrugging your lders. Start with one set o raises twice a day, and tally progress to one set -0 twice a day, making sure exercises are pain free.

Fig. 2 -1 b. To strengthen your rotator cuff muscles stand on one end of an exercise ban.d and hold on to the other end with your injured arm at your side. With your fist clenched, palm side up, bend at your elbow and pull the band up to armpit level. Start 'with one set of 5 to 15pulls twice a day with you,: injured arm, and . progress to one set of 50 pulls once a day.

Fig. 2-1d. To strengthen muscles at the fi'ont and back of your shoulder, attach an elastic exercise band to a stationary object. While standing at right angles to the band, hold the loop in front of YOUlllithyour arm bent 90 ~ strengthen the back part of the Pull the band across your deltoid, (1) holdfor a couple body slowly, (1) and slowly return to the starting position. of seconds, and slowly return Start with one set of 5 to 15 your arm to your side. Start pulls twiee a day li/ithyour with one set of 5 to 15 pulls injured arm, and progress to twice a day withyour injured one set of 50 pulls once a day. arm, and progress to one set To work different muscles at of 50 pulls once a day. To the back of your shoulder, work the fi'ont part of the deltoid, turn around and, start with your arm across your body and the band on the using the same starting other side outward. (2) position, pull the band fonvard, (2) let it back slowly, Repeat as above once these exerCises are easy, you can . and repeat as above. Once advance to a band with more these motions are ea.sy,you can advance to a band with resistance. more resistance Fig. 2-1c. To work your 'eltoid muscle, }Ilhichlies on op of the shoulder, attach an elastic exercise band to a stationary object and hold the other end next to your body slightly in fi'ont of your side. Pu II the hand backward to

EXERCISES AT HOME The tender, restricted shoulders are caused by inflammation of tendons and muscles around the shoulder joint. This condition improves spontaneously; but as pain subsides, joint stiffness develops, although this can be prevented and treated by continuous and regular upper limb motion. The following exercises are designed to hasten recovery of patient's with shoulder dysfunction . .) Straight-arm rotation (like Codman's pendulum exercise) ';Y Do this clockwise and counterclockwise for 3 to 5 minutes. _.) Shoulder stretch ';Y Put your affected arm across the opposite shoulder (trying to stretch the middle deltoid muscle), using the help of the unaffected arm to brace the affected arm to touch the sternum. 3.) Shoulder winging ';Y Intertwine your fingers behind your head, then brace the elbow posteriorly (to stretch the pectoralis major muscle.)
4.) Coupled Armswing
';Y

Supine lying with both hands together (interlocked) to make use of the good arm's strength in he!ping the affected arm do full forward flexion.

5.) Towel Exercise ';Y Put the towel on the normal shoulder, then grab the front end of the towel using the hand on the normal should~r side. Then, grab the opposite end of the towel using the affected upper extremity by internal rotation with posterior elbow flexion as in drying the back in a see-saw motion. NOTE: The pectoralis major (clavicular portion), middle deltoid, and teres minor muscles are the ones affected by tightness in shoulder dysfunction.

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elSE FOR SUBDELTOID BURSITlS4

--E SUDELTOID BURSITIS (PAINFUL SHOULDER

--ROME)
The subdeltoid bursa is the most frequent site of primary ~::is. Generally, it is the result of repeated mild trauma with the an abducted position or a single injury in which the tendons ed to the greater tuberosity of the humerus are damaged, - ~ularly when the fibers of the supraspinatus are injured.

ERCISES

dum Sl-t'inging

c.) Brinf: arm behind back

bing lot/all ith fingers w

d.) Bringing arm overhead

_-3 Shoulder exercisesfor subdeltoid bursitis.

: After the velY acute stage is over, exercises should he started
. R: Handbook of Physical Therapy, ed. 3, New York, Springer Verlag g Company, Ine 1977, p.116.
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TREA TMENT OF TENNIS ELBOW PLE CURE - THE WRINGING EXERCISE

5

rhronic tennis elbow can be cured by a simple wringing ---;"e using a small hand towel.

hod:
up a hand towel. -~ the arms extended, grasp the towel with the affected side :ed in flexion. ~n exert maximum wring pressure (Fig. 3 -1): First flexing the wrist for 10 seconds, Then, extending the wrist for 10 seconds. - an isometric' hold' contraction.

quency
This exercise should be performed only twice a day, initially ~ 10 seconds in each direction. After each week increase the time _ 5 seconds in each twisting direction until 60 seconds is reached -eek 11.) This level is maintained indefinitely.

OTE: Despite several initial pain, the patient must persist using
much force as possible. Review at 6 weeks (usually some relief by 4-6 weeks), to ensure t the patient is doing the exercise exactly as instructed. -~gh. 1.: Practice Tips, Singapore, McGraw-Hill Book Company, 1991. pp.

15

.'"

- -~. 3-1. Initial grip for 'wringing' exercise.

EXERCISES
Stretching and strengthening exercises for the forearm muscles represent the best management for tennis elbow. The muscles are strengthened by the use of hand-held weights or dumbbells. A suitable starting weight is 0.5 kg, building up, gradually (increasing by 0.5 kg) to 5 kg, depending on the patient.

Method:
.) To perform this exercise the patient sits.in a chair beside a table. _.) The arm is rested on the table so that the wrist extends over the edge . .) The weight is grasped with the palm facing downwards (Fig. 3-2a.)

.) The weight is slowly raised and lowered by flexing and extending the wrist. -.) The flexion/extension wrist movement is repeated 10 times with a rest for 1 minute and the program repeated twice.

17

This exercise should be performed every day until the patient .", play tennis, work or use the arm without pain. For medial epicondylitis (forehand tennis elbow: golfer's _.~ow), perform the same exercises but with the palm of the hand cing upward (Fig 3-2b.)
Q.

b.

~.

nf

{1

ig 3-2. Tennis Elbow: (a) dumbbell exercise for classical case (palm facing down); (b) dumbbell exercise for medial epicondylitis forehand tenniselbow (palm facing up).

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HOME EXERCISES ELBOW.6

FOR TENNIS AND GOLFER'S

The essential exercises for home rehabilitation program for - or golfer's elbow include stretching and strengthening (Fig 3-3) prove flexibility and range of motion, and to reduce forces on the --:=.-~ed tendon. Slow, passive stretching exercises and gentle ~..-,gthening exercises can be started right away.

tretching: To stretch the muscles on the top of the forearm (Fig. 3-3a), extend the elbow with the palm facing the floor, and use your other and to pull the hand down toward the inside of your forearm. (If '"here is pain, try performing the maneuver with elbow bent.) To stretch the muscle on the underside of the forearm (Fig 3-3b), turn he palm toward the ceiling, and with your other hand to pull oward the floor. Hold each stretch for 20 to 30 seconds, then relax and repeat as many times as possible within 5 minutes. Perform these stretches twice a day during rehabilitation, in addition to before and after any sports activity that involves the elbow.

Strengthening Strengthening exercises begin with wrist curls, starting with I pound weights. To strengthen the top forearm muscles (Fig. 3-3c), bend the elbow with your palm facing the floor. Curl your wrist toward the ceiling, hold the position for 10 to 15 seconds, then relax the wrist. To strengthen the muscles on the underside ( Fig. 3-3d), turn the palm towards the ceiling and again raise the weight and hold. For both maneuvers, perform three sets of 10 curls once a day, every day.
nnafin. 1. A. And Schelkun. P. H.: Home Exercises for Tennis and Golfer's w. The Physician and Sports Medicine Journal, (2~:2) Frebruary 1996: 2~(2)71 21

3-3. Stretching and strengthening exercises for tennis elbow golfer's elbow

DITIONAL EXERCISES
Other elbows muscles (pronator and supinator muscles) should -- be strengthened by holding the weight with the elbow flexed 90 - twisting clockwise and counterclockwise. Do three sets of 10 once _~/. This exercise is especially important for those who have golfer's w. To strengthen additional forearm muscles (digital extensor -des), place a heavy rubber band over the tips of all the fingers as ;::' are held together and stretch the fingers outward against it. Start :!l three sets of 10 once a day, then progress to several sessions a _". The activity can easily be done at a desk or while talking on the =-_cphone. TE: These exercises are not intended as a substitute for medical -eatment. Before starting an exercise program, consult a physician
?..., -j

TREA TMENT OF HAND INJURIES7

The treatment of injuries of the hand is common and challenging problem in the general practice of medicine. Since any injury interferes with the functioning of the hand, serious and immediate treatment of injuries is imperative. Physical therapy has an integral and important part in whatever remedial program is under taken. The guiding principles are similar in all types of injury - fracture, burns, laceration, or infection.

~ Treatment:
Following hand injury, physical therapy may be used during both the acute stage of treatment, in which the disturbance to the vascular system (as evidenced by edema) should be controlled, and during the recovery period, in which the prevention of deformity and restoration of loss of function are the main concerns of the therapist. . Movement should be started at the earliest possible moment, except when it might interfere with the healing of a fracture or soft tissue laceration, or when the resolution of an inflammatory process might be delayed. In some hand injuries, early movement is impossible because of edema, pain, or splintage. As the hand improves, the patient should be taught how to produce isometric contractions which will progress to isotonic contractions: Re-education in the use of fine coordinating movements necessary for proper use of the hand requires much time and perseverance. These movements should be explained to the patient so he can understand the aims of the treatment.

RehabH~tative Therapy:
After the acute effects of the trauma have subsided, the disability of the hand is thoroughly checked and methods of treatment are worked out to suit the

tack, R.: Handbook of Physical Therapy, ed. 3, New York Springer lishing Company Inc., 1977. p. 127-129.

25

individual's case. It is important to secure the full cooperation of the patient becat-!se certain phases of the rehabilitation procedure are painful. Active movement is most important in the restoration of lost hand movements. Passive stretching and manipulation of the small joints of the hand have absolutely no place in the treatment program; in most cases further loss of function will result from these procedures since any force applied will tear the tissues, which will heal by forming more scar tissue, in itself a barrier to movement. Active movement may consist of either exercises or occupational therapy designed to restore the lost function of the hand. Exercises are frequently prescribed. The importance of relaxation should be exrlained to the patient before exercises are begun. He should make every effort to relax all muscle groups and fatigue must be avoided. Tired muscles go into spasm which is undesirable at all stages of the treatment. Passive exercises consist of bending and straightening the patient's fingers. This is done by therapist while Jthe patient allows his fingers to be relaxed. These movements should never be forced.

27

Active exercises are performed by the patient and are done according to the fol1owiQg instructions '1.) Palm flat on the table, raise and lower fingers one by one.
2.)

Make an "0" by touching thumb to finger tips one at a time. Crumple a sheet of newspaper into a small ball with one hand. Squeeze a small rubber ball or sponge. Pick up coins or buttons or assorted sizes. Keep time to music with finger (drum with extended finger.) Rest hand on table; spread fingers wide and then bring them together. Flip balls of paper with fingers, or flip a lightweight book or folded newspaper off extended fingers. in front of chest; push against fingers of affected hand with fingers of the uninjured hand.

3.)

4.)

5.)
6.)

7.)

8.)

9.) Place hands with palms together

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LE PUMPING EXERICSES FOR EDEMA REDUCTION OF THE HAND.s alisbury and colleagues investigated the individual effects of compressive dressings, an intermittent compression devices, ~rcise on post-burn edema following deep partial thickness and full thickness (FT) hand burns. They found that the ent compression device produced the only significant decrease a during the first 72 hours post-burn. Between three and seven st-burn however, further decrease in edema occurred as a result =__ hours elevation. Despite these findings, it was suggested that : spection of the hand is more important during the first 72 hours rn than compression. Therefore, they do not recommend the ~ cclusive wraps or splints for DPT and FT burns during that ~. Instead, Salisbury and colleagues reported the use of active . -e and night elevation during the first 72 hours without -"mise to edema control and hand function. Proper elevation requires that the hand be higher than heart Elbow extension i~ particularly important if both forearm and re burned. To properly elevate the hand, suspend it via a ette attached to an intravenous pole or bedpost, mound pillows, elevation boards attached to the side of the bed. Use of a sling is __=gested because of the flexed elbow position and the. tendency of ""atients not to properly elevate the hand. :\1uscle pumping exercises should be 'performed hourly in low -:ons so as not to incite further inflammation. Muscle pumping -es include the lumbrical position and abduction-adduction of the ~s to contract the intrinsic muscles of the hand (Fig. 4.) Forced site digital flexion is discouraged, especially if the dorsum of the r fingers are burned, to lessen the risk of extensor apparatus ation. The hook position portion of the modified fist program gital composite flexion are not to be initiated until the viability of ensor tendons is known.

_11.J. W.: Management of the Acutely Burned Hand for the Non-specialized _ian. Physical Therapy. December 1989; 69(12) p.108!.

31

Fig. 4. Muscle pumping exercises for edema reduction. Modifiedfist achieved by (a)isolated metacarpophalangeal joint flexion and (b)isolated interphalangeal joint flexion. (c)Digital abduction and adduction to stretch the lveb space.

POSTURAL EXERCISES tECOMMENDED STRETCHING EXERCISES FOR SPINAL PAIN P ATIENTS(i.e., postural dysfunctions and the
-e)

The exercise in the series of illustrations have been chosen ecause of their clinical effectiveness. The exercises will be ~escribed for the different regions of the spine, for the upper ~:-.1remities, nd lower extremities. Many of the stretching a ~xercises can be enhanced by incorporating relaxation and ::lovement awareness principles. Fig. 5. Recommended stretching exercises9 lustrations 5-1 to 32 by Mike Jackson, Riverdale, GA

gian. 1. V. And Nyberg, R.: Rational Manual Therapies. Maryland. and Wilkins. 1993. pp. 368. 371-386. 35

--1. Correcting a Fonvard head Posture/Nodding

se: To decrease stress to your neck and low back. b.) To improve your spinal alignment and posture . .) Improve ability to breath through your diaphragm. d.) Increase mobility in upper cervical spine.
a.)

ption: Correct trunk position by imagining a string pulling from your chest up and forward, at a 45 degree angle. Tuck your chin straight back, keeping eyes horizontal. Nod your head gently, feeling the stretch at the base of your skull.

ments: Think tall and wide. Relax into the position with

breathing. Reps:

Sets:

Time:

37

_. Pit Look

.) To decrease neck and shoulder tension. b.) To increase neck rotation.

tion: Sitting or standing with a straight back and arms resting in lap. Drop head and neck slowly move in a forward direction, bringing chin as close to chest as possible. Repeat to the left and right, as iflooking at the arm pit..

ents: Slow, gentle, gravity assist movement. end of motion. Reps. : Sets: Time:

Breathe out at the

39

Head ~ilt and chest lift

: To increase neck and mid back mobility and improve posture .

.on: Sitting with knees bent and resting on hands, elbows

~~raight. Your therapist will tell you which head position to _se. Lift chest up towards ceiling at 45 degrees angle.

ts: Breathe in and out to increase the movement. eps.: Sets: Time:

41

. Upper and mid back rotation stretch

To increase mobility in upper and midback. .) Promote movement in chest and arm muscles.

'on: Assume a sidelying position and bend knees as close to

_'our chest as possible, to isolate motion to your mid and upper ack. Place the hand of your upper arm and head back until ='ou feel a comfortable stretch through your midback and chest. ~tay in this position through one deep breath, feeling an . crease in the movement as you exhale.

nts:
Reps.: Sets: Time:

43

- Back Hunch

To increase movement in mid back, upper arms and neck.

'on: Stand 2 to 3 feet from a wall, place hands on the wall at oulder height with elbows straight. Bend elbows and lean --wards the wall. Push back from the wall until elbows are s:raight. Tuck chin to chest as far as xou can. Then arch your 'dback.

nts: Breathe in and out at end position and repeat. Do not

-aise your shoulders towards ears during the movement. eps.: Sets: Time:

45

 5-6. Thoracic spine extension on all four

ose:To increase backward bending in upper back

ription: Kneel while propping yourself on your forearm. Keep low back flat. Drop midback towards the floor. Return to starting position.

mments:

Use exhalation to assist with the movement. Sets: Time:

Reps.:

47

- 'Yck

straightener.

increase mid-back movement and improve posture.

: Kneeling with forearms supported on a table and head g on forearms. Let upper and midback sag down towards _c_:- and then lift up.

: Breathe out at end of each sag to increase the movement. low back flat. Sets: Time:

49

Circumduction

To promote relaxation and stretching the neck and shoulder area. To stretch the mid and lower back muscles and joints.

on: Lie on your side, arms straight out in front of body . .de the top hand forward, feeling a comfortable stretch. With d in this position, slowly move top arm in a circle around _. ur body. The head and trunk will rotate as your arm moves o ehind you.

nts: Move slowly. Keep top arm relaxed. No discomfort -hould be felt. 3...eps.: Sets: Time:

51

 Prone anterior pelvic tilt

) To increase mobility in the lower lumbar spine . .) To coordinate lumbo-pelvic motion.

tion: Lie on your stomach, with a pillow under your stomach,

ilt your pelvis forwards(towards the floor) and rel<!lx. Hip ones should stay in contact with the pillow as your low back arches.

ents: Keep the amplitude of the motion within comfort. during the exhalation phase of your breathing. Reps.: Sets: Time:

Tilt

53

Forward pelvic tilt on all fours

:T 0 increase lowback backward bending .

. n: Get on hands and knees with weight evenly distributed on

four limbs.

> Keep elbows straight.

> Tilt your pelvis toward the floor while sticking buttocks
out allowing your low back to sag.

> Resume the neutral position.

ts: Use exhalation to assist with the motion.

eps.: Sets: Time:

55

Prone press up.

To increase backward bending in low back. Reduce disc pressure.

- n: Lie on stomach. Keep back and bottom muscles relaxed . .=:.ced hands at the position instructed by your therapist. ~_~)\vlypush your trunk up with your arms. Stay in this position -ough one deep breath. Feeling your back sag move as you =~:nale. Return to starting position.

ents:
Concentrate on feeling the motion occurring in' your upper and midback first and then moving into your lowback. Be sure the involve area of your back is also moving. Hips should remain in contact with the floor as you push up. eps.: Sets: Time:

57

,.J, , ,
,~"

,,

Extension in standing

Increase backward bending in the lowback. Decrease disc pressure.

on: Stand with feet shoulder width apart. Place your hands
.... the small of your back to provide support. Shift your weight 'er your feet, letting your shoulders go back and your hips .... -rward.

ts: Keep the exercise passive. Do not force the backward otion by contracting your muscles. eps.: Sets: Time:

59

Double knee to cltest

- 0 increase abdominal strength.

n: Do a pelvic tilt. Maintain the pelvic tilt as you slowly 3e both knees to your chest. The abdominal muscles will be _~king to keep your low back flat.

Sets:

Time:

61

 Foot touch

:To increase spinal flexion movement and hamstring length.

tion: Standing with one foot on stool or step slowly curl forward with arms in front so as to reach for foot or stool or step.

nts: Slow, gentle, gravity assist motion.

Reps.:

Sets:

Time:

63

Back curl

e :To increase spinal flexion movement.

ption : Sitting, legs apart and arms between legs, slowly bend ead, neck and back forward with arms in front so as to reach or the floor.

eots: Slow, gentle, gravity assist motion. Attempt to recruit; movement at each vertebra in the supine. Exhale slowly at en of movement. Reps.: Sets:. Time:

65

hinx

improve neck, trunk and shoulder mobility.

: From a hands and knee position with back straight, tuck - down toward chest and slowly shift your weight back to ro heels. Allow your back to round out. Return to starting on .
...

: You will feel a comfortable stretch from your pelvis to .. neck and through the shoulders. Exhale as you sit back at feet. s.: Sets: Time:

67

--

~runk Rotation

~0 increase spinal rotation range of motion.

- 0 stretch the muscles on the side of the hip.

-i

Lie on side with bottom leg straight and top leg flexed. =- amount of top leg flexion determines where the spinal 2-:ion occurs ( for example, when the leg flexes further the _:-al rotation is felt higher up in the back). Slide upper arm :ard along floor and then back across body while the head, lder and upper body also rotate back. Pause 1 or 2 full ;;aths in the rotated position to facilitate additional relaxation further movement.

: On the last repetition, hold rotated position for 30 to 60 -::onds. Be sure to breath slowly to enhance muscle - nation. Sets: . ~s.: Time:

69

nk side bending in stretching

increase extensibility in lateral trunk muscles. help restore lumbo-pelvic motion.

: Stand erect with feet shoulder width apart. Place your =.- .:laIldon the top of your head. Slowly side bend to the right ~ shifting your weight to the left .. Feel for a stretch along left side stay in this position through 1 deep breath and m to starting position. To stretch your right side reverse -.~ positions and directions.

: Allow the opposite hip to move slightly sideways as you -"plete the side bending motion. Do not strain while you side Sets: Time:

71

lfadratlls

/llmborum

stretch

lengthen the lateral trunk muscles.

: Lie on your right side with your knees comfortably bent. . your trunk to "sag" toward the floor. You should feel a -.:'ortable stretch along the right side of your trunk. I

: Remember to breathe, using exhalation to assist with - "'-ation and stretch. Sets: Time:

73

mstring stretch

rease hamstring length.

(

. Lie on your back with the leg to be stretched propped on __ 7" frame so that you feel a comfortable stretch from the ~:kof the knee. The other leg may be bent or straight.

se exhalation to assist with the stretch.

As you gain

ility, place your heel higher on the door frame. To vary _ ,_.,etch, rotate your foot inward and outward as you hold - 5:fetch. Sets: Time:

75

Standing hamstring stretch.

o increase hamstring length .

. n: Place your heel on an object( stair, chair) keeping your .:k and knee straight, toes toward the ceiling, so that you feel :omfortable stretch from the buttock to the back of the knee . .. ;:peat \vith the opposite leg.

ts: As your tTIuscles lengthen. over time, place the heel on a :=her object Use exhalation to assist with the stretch - eps.: Sets: Time:

77

eel cord stretch

_~ngthen calf muscles.

: Stand with one leg in front of the other and toes straight =dU. Shift weight onto front leg by flexing knee while =ning the back knee straight and the heel of your back foot in - ~act with the ground.

: Keep back foot pointed straight ahead or slightly turned _'ou feel the weight on the outside of the foot. Repeat the -~ ~edure with your knee slightly bent to lengthen the calf _scle in the lower part of your calf ~T'\S.: Sets: Time:

79

Inner thigh stretch

o lengthen inner thigh muscle.

n: Lie on your back at a door jam. Bend the hip and knee of
'" leg facing the free corner and Qlace the oQQosite heel on the -eeping your knee straight. Allow the straight leg to slide he wall until you feel a stretch in your inner thigh and

_-\5 you stretch out you should be able to move your m closer to the wall. Sets: Time:

81

thigh stretch

--gthen inner thigh muscle.

__~ on your back at a door jam. Bend the hip and knee of ; a~ing the free corner and place the opposite heel on the __;-,ing your knee straight. Allow the straight leg to slide ~ wall until you feel a stretch in your inner thigh and

- ~ you stretch out you should be able to move your -loser to the wall. Sets: Time:

81

"'.-24. Tensor stretch

se: To stretch muscles on outside of thigh.

'ption: Cross leg nearest the wall behind other leg. Lean hips in towards the wall until a stretch is felt on t.he outside of the hip and thigh.

ents:
Reps.: Sets: Time;

,83

Leg drop

Lengthen muscles in front of hip and thigh. Correct pelvic imbalance.

n: Lie on your back with your hips at the edge of a table. - ~ d __ knee to your chest. Drop __ leg gently towards floor. Keep your low back flat. .Hold position for __ .
:>

85

~unge.

stretch the muscles in front of the hip and groin.

: Kneel on one knee. Shift weight forward onto front foot . g sure back remains straight.

: A stretch should be felt in front of the hip and thigh of the -leg. Time: Sets:

87

anding quadriceps stretch

- -.-etchmuscles in front of the thigh.

: Stand beside a table or chair and hold on with one hand - -alance. Bend the opposite knee and hold the ankle with - free hand. -Pull ankle up towards your bottom until you stretch in front of your thigh. : Keep your pelvis level and your back flat. Sets: Time:

89

:-28. Buttock stretch

.lie:

To promote motion of the buttock muscles in order to increase hip mobility.

ption: Cross your left leg over your right leg grasping left knee with your right hand. Move your left knee towards the right shoulder with your right arm. Repeat to the opposite direction or the opposite leg.

-- The leg that is not being stretched may be straight rather

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te,e,\

a \.()\1\\()\\a\)\t ~\.\t\.\'\\ ~~~~ \\\ \\\~

---\.. "\ a\.~ '1\) \n.e, ~\ac,\. ot \n.i m\1~c,\e,~\e,\a-x. \\\1\\\\%

lon. Be sure to keep your trunk on the floor. Sets: Time:

91

 . vist

..- and stretch the muscles on the outside (jfthe hip

-c ~xercise the right side: sit on the floor with your rig ..
over your left leg. Place left elbow on the outside ~.~ knee. While loo.king toward your right hand, slo ... - bent leg with your arm to the left until you feel a ..:n along buttock, hip and outside of the right thigh h the opposite leg.
oJ

le

as you stretch and take up the slack as the mUSCleSets: Time:

93

- s:-etch muscles along the outside of the hip ~."-'-':er back rotation.

~eft side: ..ith your right knee crossed over the left. Ider blades on the floor, slowly drop your :: G:1tiJ you feel a mild stretch along the left side - and hip. Hold. Return to the starting - -~ the opposite side with the left knee over the
=

- ::.ssistwith the stretch. _=IS: Time:

95

Frog leg exercise

To lengthen the muscles in the inside and front of the thigh and hip. To improve low back side bending.

on: Lie on your stomach. Place the bottom of one foot flat gainst the inside of the calf of the opposite leg. Slide knee up and out to the side. Return to the starting position.

"'"-~-

Time:

97

 5-32. Pulldowns

ose: Lengthen muscles in the front of the chest and improve control of the shoulder blade stabilizer and improve posture.

cription: Start with the arms overhead, palms together keep a 90 degree angle between arm and elbow. Bring arms down and back as if trying to place elbows into your back pockets. mments: Reps.: Sets: Time:

99

- 33. Arm stretch

se: To stretch the back of the arm.

'ption: Sitting or standing with back straight. One hand reaches behind same shoulder and the other is placed on the elbow. Push elbow back slowly and gently. ents: Breathe into the stretch. Do not let low back arch. Reps.: ~ets:. Time:

101