Chapter 16: The Spine: Exercise and Manipulation Interventions

The basic anatomy, spinal mechanics, and posture are presented in Chapter 14. In Chapter 15, the pathomechanics, common pathologies, and management guidelines related to the spine are presented. The management guidelines are outlined based on stages of healing as well as subgroupings based on diagnostic categories that reflect impairments and movement disorders. Chapter 16 is a continuation of this material in which the techniques of intervention using mobilization/manipulation and therapeutic exercise for management of neck and trunk impairments are described.

This chapter is divided into six main sections. The first section describes the underlying concepts and approaches to exercise interventions. Each of the remaining five sections describes elements of physical function for the neck and trunk. The topics covered in these sections include exercises for kinesthetic awareness, mobility/flexibility, muscle performance (including stability, muscle endurance, and strength), cardiopulmonary endurance, and functional activities. Stress relief and relaxation principles and techniques, important components of total rehabilitation, are covered in detail in Chapter 14.

It is important to recognize that, even though the material in this chapter is presented in separate sections, there is an overlap in the use of the techniques described in each section, and there are fundamental interventions basic to all exercise programs.

Fundamental Interventions

When patients seek treatment from a physical therapist, they come with different diagnoses, impairments, and functional limitations and are at different stages of tissue healing. Yet the treatment plan for each patient must begin with fundamental interventions in order to lay the foundation on which to build an effective therapeutic exercise program. Fundamental interventions are defined as exercises or skills that all patients with spinal impairments should learn regardless of their functional level at the time of examination and initial treatment. The interventions include basic kinesthetic training, basic spinal stabilization training, and functional training of basic body mechanics. These interventions are summarized in Box 16.1.

Once the fundamental skills are learned, exercise interventions then progress on a continuum at the level of the patient's abilities and willingness to learn. For example, a patient beginning treatment with chronic symptoms several months after the onset of symptoms must first become aware of positions or activities that increase the symptoms, and then learn how to move the spine safely as well as learn what effects the various postures and movements have on symptoms (fundamental kinesthetic awareness). The patient must learn how to activate the deep segmental stabilizing musculature and then how to use the deep stabilizers with the global musculature to stabilize the spine against various extremity loading exercises (fundamental muscle performance). Finally, the patient must learn basic body mechanics (fundamental functional activities) in order to minimize stresses to the spine during daily activities before progressing to exercises that can be tolerated at the chronic stage of healing and returning to desired functional activities. The fundamental exercises are described in detail preceding the exercise progressions in each of the respective sections of this chapter. The principles of management are similar for the cervical and lumbar spinal regions, and many of the same techniques may be used or modified for both regions.

Patient Education

Patient education is the key component of every goal and intervention. It encompasses several ideas. First, the patient is an active participant in identifying the desired outcomes; education as to potential outcomes is part of this process. Second, the patient may need to be educated about limitations at each stage of healing, so he or she will not become concerned that the acute symptoms will be forever disabling and will not "overdo" exercises and activities during the early sub-acute phase and cause exacerbation of symptoms. The patient may then need to be challenged to progress beyond perceived limitations during the later stages of recovery.

To ensure that each individual develops control over and learns to manage the symptoms and any impairments, it is important that the patient is engaged in all activities at each stage of recovery and is not just a passive recipient of "treatment." The patient needs to be instructed on how to safely progress self-management beyond the time spent under professional supervision so he or she can reach the maximum level of functional return with minimal activity or participation restrictions.

Finally, the patient needs instruction in prevention. This includes safe ways to exercise, safe body mechanics for return to high-intensity activities, modification of the work and home environment, and activities to minimize stresses.

General Exercise Guidelines

Therapeutic exercise is an important intervention in the management of impairments in the spinal region. Although this text does not deal with specific examination techniques, it is critical to emphasize the importance of identifying each patient's structural and functional impairments, their activity and participation restrictions (functional limitations), and the stage of tissue healing or stage of rehabilitation in order to establish a baseline for the initiation of intervention techniques and to measure progress toward the outcome goals. In many cases, tissue healing, stages of rehabilitation, and functional expectations parallel one another (Table 16.1).

In general, the following elements of physical function are used in all intervention programs for spinal problems. These five areas are listed in Table 16.2 with interventions for each stage of rehabilitation. The interventions are described in detail in the remaining sections of this chapter. Prior to developing an exercise program, it is important that the reader has knowledge of various spinal pathologies and the special precautions and contraindications (see Chapter 15), so each patient can safely achieve his or her maximum potential.

Kinesthetic Awareness

One of the fundamental interventions for spinal rehabilitation is to develop patient awareness of safe spinal positions and spinal movement as well as what effect the supine, prone, side-lying, sitting, and standing positions have on the spine. Awareness of what postures make the symptoms better or worse and identifying the neutral spinal position or position of bias are important in helping patients manage their symptoms. Awareness and control of spinal posture and movement are progressed and incorporated into all the exercises described in the remaining sections of this chapter and underlie exercises for the extremities as well.

Mobility/Flexibility

Stretching and flexibility exercises as well as mobilization/manipulation techniques are used to increase mobility of restricting tissues, so the patient can assume an effective position of the spine when exercising to improve muscle performance and functional outcomes. For patients who fit the Mobilization/Manipulation diagnostic category (described in Chapter 15), spinal manipulation techniques or specific high-velocity thrust techniques (HVT) may be indicated during the early intervention period and then followed with stretching exercises.

NOTE: The terms mobilization and manipulation are currently being used interchangeably, with a trend towards using the term manipulation (see Chapter 5). The authors of this chapter are using manipulation to refer to graded oscillation techniques, and high-velocity thrust (HVT) to refer to high-velocity, small-amplitude motion performed at the end of the pathological limit of the joint.

Muscle Performance

In the spine, muscle performance involves not only strength, power, and endurance but also stability. Activation of the deep segmental-stabilizing muscles and exercises to develop spinal control in the global stabilizing muscles are fundamental for developing spinal stability. Emphasis is placed on awareness of muscle contraction and control of spinal position while moving the extremities. Exercises are then progressed to challenge the holding capacity of the stabilizing muscles, emphasizing muscle endurance, balance, and strength. Once the individual learns effective stabilization and management of symptoms, dynamic neck and trunk strengthening exercises are initiated. Most people are familiar with trunk curls, "crunches," and back lifts. The emphasis of therapeutic exercise is safe execution of the exercises combined with respect of the biomechanics of the spine. Exercises should be chosen with the functional outcome goals in mind and integrated with the principles discussed in the 'Functional Activities' section.

Cardiopulmonary Endurance

Aerobic conditioning exercises are initiated as soon as the patient tolerates repetitive activity without exacerbating symptoms. Emphasis is placed on using safe spinal postures while exercising. Aerobic activity increases the patient's feeling of well-being and improves cardiovascular and pulmonary fitness. Principles of aerobic conditioning are detailed in Chapter 4 and summarized in this chapter along with suggestions for safe application of aerobic exercises when there are spinal impairments.

Functional Activities

Fundamental functional activities include training the basic body mechanics of rolling, supine to sit, sit to stand (and reverse), walking. These activities are coordinated with kinesthetic training and segmental muscle activation and stabilization exercises. When the patient is able, stabilization exercises, muscle endurance, and strengthening exercises are integrated with skills for body mechanics (lifting, pushing, pulling, carrying), safe work habits (ergonomic adaptations), and effective recreational or sport activities to meet the goals of the individual.

Goal. To develop proprioception of spinal positioning, safe movement, and postural control.

Elements of Functional Training: Fundamental Techniques

Position of Symptom Relief

The patient must learn how to move the spine and find the range or position in which symptoms are minimized. The position of symptom relief is called the position of bias or the resting position. The neutral spine position is mid-range; the patient may or may not feel most comfortable in that position initially. See Chapter 15 for a discussion on spinal bias as it relates to relief of symptoms and common pathologies.

Cervical Spine

Patient position and procedure: Begin supine; progress to sitting and other functional postures as tolerated.

• Passively move the head and neck with gentle nodding motions of the head into flexion and extension, side bending, and/or rotation to find the most comfortable position for the patient. If necessary, prop the head and neck with pillows.

• Describe the mechanics of what you are doing to the patient.

• Have the patient identify the change in symptoms as movement occurs in and out of the position of bias.

• Have the patient practice moving into and out of that position to develop control.

• If the patient cannot maintain this position while sitting and standing, wearing a cervical collar may be appropriate during the acute stage, but it is important to use judiciously, so the patient does not become dependent on it.

Lumbar Spine

Patient position and procedure: Begin supine or hook-lying, then sitting, standing, and quadruped.

• Teach the patient to move his or her pelvis into an anterior and posterior pelvic tilt (PT) through the range that is comfortable.

• Once the patient has moved the pelvis and spine through a safe range of motion (ROM), instruct him or her to find the position of greatest symptom relief.

• If active movement and control are not possible, teach passive positioning (see Box 15.6). Have the patient assume each of the following positions, and draw the association between the spinal position and what is felt. While supine, passively position the pelvis in posterior PT by placing the lower extremities in the hook-lying position or anterior tilt by gently pulling on the extended legs or placing a small roll under the lumbar spine. Sitting encourages spinal flexion; if extension is more comfortable, instruct the person to use a lumbar pillow for support. Standing usually causes spinal extension; if flexion is desired, instruct the person to place one foot up on a stool while standing.

Effects of Movement on the Spine

Once the functional spinal position is determined, it is important for the patient to feel and learn what motions make the symptoms better or worse. In general, movement of the extremities away from the trunk (shoulder flexion and abduction, hip extension and abduction) causes spinal extension; movement of the extremities toward the trunk (shoulder extension and adduction, hip flexion and adduction) causes spinal flexion.

• Have the patient find the neutral or functional spine position (bias); then move the arms and then the legs to feel the effect on the spine. Control of the spinal position is emphasized; have the patient practice the arm and leg motions and attempt to maintain control of the spinal position. These motions are the same as the basic stabilization exercises and are described in detail in the muscle performance section.

• If the patient cannot maintain control or the symptoms are made worse, he or she requires passive support or passive positioning when initiating the stabilization exercises.

Blending of Kinesthetic Training, Stabilization Exercises, and Fundamental Body Mechanics

Once awareness of safe positions and movement is learned, teach the patient the fundamental stabilization techniques for developing neuromuscular control of the position ('Muscle Performance' section), and teach the fundamental body mechanics of rolling, moving supine to sit, sit to stand, and ambulation ('Functional Activities' section).

Progression to Active and Habitual Control of Posture

Awareness and control of posture is described in detail in Chapter 14 (see 'General Management Guidelines for Impaired Posture' and Box 14.1). The use of reinforcement techniques (verbal, visual, tactile) is described, as are activities to train cervical, scapular, thoracic, and lumbopelvic alignment and control. It is important to reinforce the relationship between faulty posture and the development of painful symptoms and to identify a need for postural support (temporary or long-term).

Integrate the awareness of posture and control of the spinal segments into all stabilization exercises, aerobic conditioning, and functional training activities. Observe the patient as greater challenges to activities are performed and, if necessary, provide reminders to find the neutral spinal position and to initiate contraction of the stabilizing muscles prior to the activity. For example, when reaching overhead, help the patient become aware of the need to contract the abdominal muscles to maintain a neutral spine position and not allow the spine to extend into a painful or unstable range; this is practiced until the stabilization becomes habitual. This principle is also incorporated into body mechanics, such as when going from picking up and lifting to placing an object on a high shelf, or into sport activities when reaching up to block or throw a ball.

Goal. To increase ROM of specific structures that affect alignment and mobility in the neck and trunk.

In general, stretching is contraindicated in the region of inflamed tissue. However, if there are postures that relieve symptoms but are difficult to assume because of tissue restriction or fluid stasis, stretching or repetitive movement into the restricted range may be appropriate. For example, repetitive lumbar extension has been shown to relieve symptoms of fluid stasis or a disc lesion (see Chapter 15), yet a patient may not be able to get into an extended posture because of flexed postural dysfunction or swollen tissue. Prone propping and press-ups may stretch the tight tissue or may compress and massage swollen disc material or fluid stasis to reduce symptoms (see Fig. 15.7). (Management of disc lesions is described in Chapter 15.)

Acute nerve root irritation from boney spurs or lipping in an arthritic spine is another situation in which acute symptoms may be relieved with stretching. Reducing pressure on the nerve roots with a stretch traction force, which widens the intervertebral foramina, or with procedures that help position the spine in its optimal spinal position may relieve the symptoms.¹

Decreased mobility in structures in the upper and lower extremities that restrict normal postural alignment may be stretched or mobilized if the techniques do not stress the area of inflammation.

Stretching is done on a continuum. Critical judgment is used to determine the intensity and duration of stretch based on proximity to the healing tissue and the integrity and tolerance of the tissue. Principles of stretching for impaired mobility are described in Chapter 4.

Joint manipulation techniques and specific high-velocity thrust techniques may be used to stretch a hypomobile facet joint capsule. Principles of joint manipulation are described in Chapter 5; indications for their use in the spine are identified in Chapter 15 in the 'Management Guidelines: Mobilization/Manipulation' section.

If indicated, the patient is also taught general stress-relieving movements to reduce fluid stasis after being in prolonged postures. These movements are described in Chapter 14 in the 'Management of Impaired Posture' section.

Cervical and Upper Thoracic Region: Stretching Techniques

Techniques to Increase Thoracic Extension

Self-Stretching

• Patient position and procedure: Hook-lying, with the hands behind the head and the elbows resting on the mat. Progress with both arms elevated overhead while maintaining back flat on the mat. To increase the stretch, place a pad or rolled towel lengthwise under the thoracic spine between the scapulae. Incorporate breathing exercises to increase mobility of the rib cage and assist with thoracic extension. Have the patient start with the elbows together in front of the face and then inhale as the elbows are brought down to the mat; hold the stretch position; then exhale as the elbows are brought together again.

• Patient position and procedure: Supine, with a foam roll placed longitudinally down the length of the spine. If the patient cannot balance on the roll or experiences tenderness along the spinous processes from pressure, tape two foam rolls together. The patient elevates both arms overhead in a "touchdown" position and allows gravity to apply the stretch force (Fig. 16.1 A). The patient then abducts and laterally rotates both shoulders (90/90 position) so the hands are facing the ceiling (Fig. 16.1 B). This position also stretches the pectoralis major and subscapularis muscles. Breathing exercises can be added to mobilize the ribs.

• Patient position and procedure: Sitting on a firm, straight-backed chair with the hands behind the head or held abducted and externally rotated 90°. The patient then brings the elbows out to the side as the scapulae are adducted and the thoracic spine is extended (head held neutral, not flexed). To combine with breathing, have the patient inhale as he or she takes the elbows out to the side and exhale as the elbows are brought in front of the face (Fig. 16.2).

Techniques to Increase Axial Extension (Cervical Retraction): Scalene Muscle Stretch

Manual Stretching

Patient position and procedure: Sitting. The patient first performs axial extension (tucks the chin and straightens the neck) and then side bends the neck opposite and rotates it toward the tight muscles. Stand behind the patient and stabilize the head with the one hand around the side of the patient's head and face, holding the head against your trunk or shoulder. Place the other hand across the top of the rib cage on the side of tightness (Fig. 16.3). Instruct the patient to inhale and exhale; apply a downward pressure (resisting elevation of the rib cage) as the patient inhales again. As the patient relaxes (exhales), take up the slack. Repeat. This is a gentle, hold-relax stretching maneuver. This technique can also be done in supine.

Self-Stretching

Patient position and procedure: Standing next to a table and holding onto its underside. The patient positions the head in axial extension, side bends opposite, and rotates toward the same side as the muscle being stretched. To stretch, he or she leans away from the table, inhales, exhales, and holds the stretch position.

Techniques to Increase Upper Cervical Flexion: Short Suboccipital Muscle Stretch

Manual Stretching

Patient position and procedure: Sitting. Identify the spinous process of the second cervical vertebra and stabilize it with your thumb or with the second metacarpophalangeal joint (and the thumb and index finger around the transverse processes). Have the patient slowly nod, doing just a tipping motion of the head on the upper spine (Fig. 16.4). Guide the movement by placing the other hand across the patient's forehead.

Self-Stretching

Patient position and procedure: Supine or sitting. Instruct the patient to first perform a chin tuck (axial extension), then nod the head, bringing the chin toward the larynx until a stretch is felt in the suboccipital area.

• Have the patient put a light pressure under the occipital region with the palm of his or her hand while tipping the head forward to reinforce the motion.

• For a unilateral stretch, instruct the patient to first perform a chin tuck, rotate slightly (up to 45°) to the left or right, and then nod.

NOTE: The weight of the head is enough stretch force in these exercises; the patient should not pull on the head when there is cervical pathology.

Traction as a Stretching Technique

Manual Traction: Cervical Spine

Traction techniques can be used for the purposes of stretching the muscles and the facet joint capsules and widening the intervertebral foramina.⁵⁴ The value of manual traction is that the angle of pull, head position, and placement of the force (via specific hand placements) can be controlled by the therapist; thus, the force can be specifically applied with minimum stress to regions that should not be stretched.

Patient position: Supine on a treatment table. The patient should be as relaxed as possible.

Therapist position and hand placement: Standing at the head of the treatment table, supporting the weight of the patient's head in the hands. Hand placement depends on comfort, the size of the patient's head and the therapist's hands. Suggestions include:

• Place the fingers of both hands under the occiput (Fig. 16.5 A), or with the hands on the sides of the face (not covering the ears).

• Place one hand over the forehead and the other hand under the occiput (Fig. 16.5 B).

• Place the index fingers around the spinous process above the vertebral level to be moved. This hand placement provides a specific traction only to the vertebral segments below the level at which the fingers are placed. A belt around the therapist's hips can be used to reinforce the fingers and increase the ease of applying the traction force (Fig. 16.5 C).

Procedure: Vary the patient's head position in flexion, extension, side bending, and side bending with rotation until the tissue to be stretched is taut; then apply a traction force by assuming a stable stance and leaning backward in a controlled manner. If a belt is used, the force is transmitted through the belt. The force is usually applied intermittently with smooth and gradual building and releasing of the force. The intensity and duration are usually limited by the therapist's strength and endurance.

Self-Traction: Cervical Spine

Patient position and procedure: Sitting or lying down. Have the patient place his or her hands behind the neck with the fingers interlocking; the ulnar border of the fingers and hands are under the occiput and mastoid processes. The patient then gives a lifting motion to the head. The head and spine may be placed in flexion, extension, side bending, or rotation for more isolated effects. He or she may apply the traction intermittently or in a sustained manner.

NOTE: Various forms of mechanical traction can be used in the clinical setting and at home. The position, dosage, and duration of traction are determined by the therapist. Instruction for use of the equipment is not described in this text.

Cervical Joint Manipulation Techniques

Principles of joint mobilization/manipulation are discussed in detail in Chapter 5. As previously noted, the terms mobilization and manipulation are currently being used interchangeably, with a trend towards using the term manipulation. The authors of this chapter are using manipulation to mean graded oscillation techniques, and high-velocity thrust (HVT) to mean high-velocity, small-amplitude motion performed at the end of the pathological limit of the joint (see clinical tip below).

Spinal manipulation is indicated for pain modulation and to improve range of motion. Although the application of HVT techniques is appropriate for the thoracic, lumbar, and sacral spinal areas (described later in this chapter), HVT for the cervical spine is beyond the scope of this textbook. Common cervical joint manipulation techniques, with the exception of craniocervical region, are described in this section. For the craniocervical region, muscle energy techniques are described to improve mobility at the occipito-atlantal and atlanto-axial joints

PRECAUTIONS:

• If a manipulation procedure causes a change in sensation or an increased pain to radiate down an extremity, or if a patient reports a feeling of dizziness or light-headedness, do not perform additional manipulations.

• Use extreme caution if the patient reports either a current history of corticosteroid use or excessive pain.

CONTRAINDICATIONS:

• Unhealed fracture

• History of joint or ligamentous laxity caused by trauma or systemic diseases, such as rheumatoid arthritis

• Vertebral artery disease or occlusion

• Acute joint inflammation/irritation

• Cauda equina symptoms

Manipulation to Increase Cervical Flexion

Patient position: Prone with arms resting comfortably at patient's side (Fig. 16.6). Place a pillow under the clavicular region for patient comfort and to promote a neutral cervical-thoracic curve.

Therapist position and hand placement: Stand on one side of the patient with your body facing toward his or her head. Use a two-thumb contact on the spinous process of the superior restricted segment of the three-joint complex.

Manipulation force: Using force through the thumbs, slide the superior vertebra in a cephalad-anterior direction.

Manipulation to Increase Cervical Extension

Patient position: Prone with arms resting comfortably at patient's side, use a pillow for patient comfort and to promote a neutral cervical-thoracic curve (Fig. 16.7).

Therapist position and hand placement: Stand at the head of the patient with your body facing toward his or her feet. Use a two-thumb contact on the spinous process of the superior restricted segment of the resticted three-joint complex.

Manipulation force: Using force through the thumbs, slide the superior vertebra in a caudal-posterior direction.

Manipulation to Increase Cervical Rotation

Patient position: Prone with arms resting comfortably at patient's side, use a pillow for patient comfort and to promote a neutral cervical-thoracic curve (Fig. 16.8).

Therapist position and hand placement: Stand on one side of the patient with your body facing toward their head. Use a two-thumb contact on the transverse process on the superior restricted vertebrae of the three-joint complex to cause rotaton toward the direction of restriction.

Manipulation force: Using force through the thumbs, slide the superior vertebra in a cephalad-anteromedial direction.

Manipulation to Increase Cervical Rotation and Side Bending

This technique increases the diameter of the ipsilateral fora-men, as seen with contralateral rotation and side bending (Fig. 16.9) VIDEO 16.1 .

Patient position: Supine.

Therapist position and hand placement: Stand at the head of the patient with one hand (the hand opposite the side of restriction) supporting the head and the other hand in contact with the lateral aspect of the verterbra to be manipulated. The medial side of the second MCP joint should be in contact with the edge of the facet and pillar to be manipulated and the rest of your hand relaxed on the postero-lateral portion of the patient's neck. Passively place the patient's head and neck into flexion, contralateral rotation, and side bending to take up the slack until the segment to be treated is identified.

Manipulation force: Using force through the metacarpal joint of the second digit, slide (or upglide) the cervical facet in an anterior-superior-medial direction at a 45° angle.

Manipulation to Increase Cervical Rotation and Side Bending: Alternate Technique

This technique decreases the diameter of the ipsilateral foramen, as seen with ipsilateral rotation and side bending (Fig. 16.10) VIDEO 16.1 .

Patient position: Supine.

Therapist position and hand placement: Stand at the head of the patient with one hand (the hand opposite the side of restriction) supporting the patient's head and the other hand in contact with the verterbra to be manipulated. The medial side of the second MCP joint should be in contact with the edge facet and pillar to be manipulated and the rest of your hand relaxed on the postero-lateral portion of the patient's neck. Passively place the patient's head and neck into extension, ipsilateral rotation, and side bending to take up the slack until the segment to be treated is identified.

Manipulation force: Using force through the MCP joint of the second digit, slide (or downglide) the cervical facet in an inferior-medial direction at a 45° angle.

Muscle Energy Techniques to Increase Craniocervical Mobility

Muscle energy (ME) uses the application of submaximum, isometric contractions of muscles whose line of pull can cause the desired accessory motion of a joint; ME techniques are designed to improve joint mobility (see Chapter 5). The patient holds the gentle muscle contraction against the therapist's graded resistance for 3 to 5 seconds and then relaxes. This process is repeated for three to five repetitions. When performed correctly, ME techniques are extremely safe and are indicated for most joint restrictions resulting from musculoskeletal disorders.

PRECAUTION: Great care should be used when applying the following techniques so as not to occlude the vertebral artery. The therapist should test the integrity of the vertebral artery prior to performing the following ME techniques. Do not perform ME techniques if the patient reports an altered sensation in either upper extremity or a feeling of dizziness or light-headedness during the set-up of these techniques.

To Increase Craniocervical Flexion

Patient position: Supine, with hands placed comfortably at the side (Fig. 16. 11) VIDEO 16.2 .

Therapist position, hand placement, and patient effort: Stand at the head of the treatment table. Support the occiput with one hand and place the other hand across the forehead. Ask the patient to look upward gently as if nodding the head backwards and apply resistance against the patient's occiput, creating a gentle isometric contraction in the suboccipital muscles. When the patient relaxes, take up the slack by passively nodding the head through any new range.

Alternate technique: Sit on a stool at the head of patient with your forearms resting on the treatment table. One hand stabilizes the C2 vertebra by grasping the transverse processes between the proximal portions of the thumb and index finger; the other hand supports the occiput. Passively nod the patient's head with the hand under the occiput to take up the slack of the suboccipital muscles; then ask the patient to roll the eyes upward. This causes a gentle isometric contraction of the suboccipital muscles. The patient keeps looking upward for 3 to 5 seconds and then relaxes. After the patient relaxes, take up the slack by passively nodding the head through any new range. Repeat this procedure three to five times or until the desired outcome is achieved. Only motion between the occiput and C2 should occur. The contraction is gentle in order not to cause overflow into the multi-segmental erector spinae and upper trapezius muscles. This technique uses a gentle hold-relax, (Chapter 4) of the rectus capitis posterior minor muscle.

To Increase Craniocervical Rotation

Patient position: Supine, with hands placed comfortably at the side (Fig. 16.12) VIDEO 16.2 .

Therapist position, hand placement, and patient effort: Stand at the head of the patient. Wrap hands around the side of the patient's head with fingers under the occiput. Place the patient's head in end-range cervical flexion. Next, rotate his or her head in the direction of the restriction (for example, with restricted rotation to the left, place head in end-range left rotation). Once the patient is at end-range, instruct the patient to look in the opposite direction (example, toward the right) while you resist this movement with gentle pressure against the the side of the head. After a 3 to 5-second hold, have the patient relax and move the head into greater rotation. Repeat as needed.

Mid and Lower Thoracic and Lumbar Regions: Stretching Techniques

Techniques to Increase Lumbar Flexion

PRECAUTION: If flexion of the spine causes a change in sensation or causes pain to radiate down an extremity, reassess the patient's condition to determine if flexion is contraindicated.

Self-Stretching

• Patient position and procedure: Hook-lying. Have the patient first bring one knee and then the other toward the chest, clasp the hands around the thighs, and pull them to the chest, elevating the sacrum off the mat (Fig. 16.13). The patient should not grasp around the tibia; it places stress on the knee joints as the stretch force is applied.

• Patient position and procedure: Quadruped (on hands and knees). Have the patient perform a posterior pelvic tilt without rounding the thorax (concentrate on flexing the lumbar spine, not the thoracic spine), hold the position, then relax (Fig. 16.14 A). Repeat; this time bring the hips back to the feet, hold, and then return to the hands and knees position (Fig. 16.14 B). This also stretches the gluteus maximus, quadriceps femoris, and shoulder extensor muscles.

Techniques to Increase Lumbar Extension

PRECAUTION: Do not perform if extension causes a change in sensation or causes pain to radiate down an extremity (see Chapter 15).

Self-Stretching

• Patient position and procedure: Prone, with hands placed under the shoulders. Have the patient extend the elbows and push the thorax up off the mat but keep the pelvis down on the mat. This is a prone press-up (Fig. 16.15 A). To increase the stretch force, the pelvis can be strapped to the treatment table. This exercise also places the hip flexor muscles and soft tissue anterior to the hips in an elongated position, although it does not selectively stretch these tissues.

• Patient position and procedure: Standing, with the hands placed in the low-back area. Instruct the patient to lean backward (Fig. 16.15 B).

• Patient position and procedure: Quadruped (hands and knees). Instruct the patient to allow the spine to sag, creating lumbar extension. Alternating between this motion and a posterior pelvic tilt (as in Fig. 16.14) can be used to teach the patient how to control pelvic motion.

Techniques to Increase Lateral Flexibility of the Spine

Stretching techniques to increase lateral flexibility are used for intervention when there is asymmetrical flexibility in side bending as well as in the management of scoliosis. It is important to note that stretching has not been shown to correct or halt progression of structural scoliosis. If these exercises are used for patients with structural scoliosis, they may be beneficial in gaining some flexibility prior to surgical fusion of the spine for correcting a scoliotic deformity. They may also be used to regain flexibility in the frontal plane when muscle or fascial tightness is present with postural dysfunction. All of the following exercises are designed to stretch hypomobile structures on the concave side of the lateral curvature.

When stretching the trunk, it is necessary to stabilize the spine either above or below the curve. If the patient has a double curve, one curve must be stabilized while the other is stretched.

• Patient position and procedure: Prone. Stabilize the patient (manually or with a belt) at the iliac crest on the side of the concavity. Have the patient reach toward the knee with the arm on the convex side of the curve while stretching the opposite arm up and overhead (Fig. 16.16). Instruct the patient to breathe in and expand the rib cage on the side being stretched.

• Patient position and procedure: Prone. Have the patient stabilize the upper trunk (thoracic curve) by holding onto the edge of the mat table with the arms. Lift the hips and legs and laterally bend the trunk away from the concavity (Fig. 16.17).

• Patient position and procedure: Heel-sitting. Have the patient lean forward so the abdomen rests on the anterior thighs (Fig. 16.18 A); the arms are stretched overhead bilaterally; and the hands are flat on the floor. Then have the patient laterally bend the trunk away from the concavity by walking the hands to the convex side of the curve. Hold the position for a sustained stretch (Fig. 16.12 B).

• Patient position and procedure: Side-lying on the convex side of the curve. Place a rolled towel at the apex of the curve, and have the patient reach overhead with the top arm. Stabilize the patient at the iliac crest. Do not allow the patient to roll forward or backward during the stretch. Hold this position for a sustained period of time (Fig. 16.19).

• Patient position and procedure: Side-lying over the edge of a mat table with a rolled towel at the apex of the curve and the top arm stretched overhead. Stabilize the iliac crest. Hold this head-down position as long as possible (Fig. 16.20).

Techniques to Increase Hip Muscle Flexibility

Hip muscles have a direct effect on spinal posture and function because of their attachment on the pelvis. It is important that they have adequate flexibility for proper pelvic and spinal alignment. See Chapter 20 for specific stretching techniques of hip musculature.

Traction as a Stretching Technique

Manual Traction: Lumbar Spine

Manual traction is not as easily applied in the lumbar region as in the cervical region. At least one-half of the patient's body weight must be moved, and the coefficient of friction of the part to be moved also must be overcome to cause vertebral distraction and stretching. It is helpful to place the patient on a split-traction table for ease in moving and stretching the spine. Patient position: Supine or prone. Stabilize the thorax with a harness secured to the head end of the table or have an assistant stabilize the patient by standing at the head of the table and holding the patient's arms. Position the patient so there is maximal stretch on the hypomobile tissue.

• To stretch into extension, extend the hips.

• To stretch into flexion, flex the hips.

• To stretch into side bending, move the lower extremities to one side.

Therapist position and procedures: Position yourself so effective body mechanics and body weight can be used.

• If the lower extremities are extended to emphasize spinal extension, exert the pull at the ankles.

• If the lower extremities are flexed to emphasize spinal flexion, drape both of the legs over your shoulder that is closest to the mid-line of the table and exert the stretch force with your arms wrapped across the patient's thighs. As an alternative, place a pelvic belt with straps around the patient and manually pull on the straps.

• For unilateral impairments, pull on one extremity.

Positional Traction: Lumbar Spine

The value of positional traction is that the primary traction force can be directed to the side on which symptoms occur, or it can be isolated to a specific facet, making it beneficial for selective stretching.

Patient position: Side-lying, with the side to be stretched uppermost. A rolled blanket or thick towel is placed under the spine at the level where the traction force is desired; this causes side bending away from the side to be treated and, therefore, an upward gliding of the facets (Fig. 16.21 A). Therapist position: Standing, at the side of the treatment table facing the patient. Determine the segment that is to receive most of the traction force and palpate the spinous processes at that level and the level above.

Procedure: The patient relaxes in the side-bent position. Rotation is added to isolate a distraction force to the desired level. Rotate the upper trunk by gently pulling on the arm on which the patient is lying while simultaneously palpating the spinous processes with your other hand to determine when rotation has arrived at the level just above the joint to be distracted. Then flex the patient's uppermost thigh, again palpating the spinous processes until flexion of the lower portion of the spine occurs at the desired level. The segment at which these two opposing forces meet now has maximum positional distraction force (Fig. 16.21 B).

Thoracic and Lumbar Joint Manipulation and HVT Techniques

Joint manipulation and HVT techniques have been shown to have minimal risk to patients^7,15 and also to be an effective intervention for spinal pain.^{7,9,11,12,15,63} Although HVT has been practiced in physical therapy since the 1920s,⁴⁵ these techniques should not be performed by physical therapist assistants or physical therapy aides.^3,45 The indications for joint manipulation and HVT are discussed in Chapter 5.

High-velocity thrust techniques may be easier to perform if the application of the force is coordinated with the patient's breathing. Instruct the patient to breathe deeply several times and on the final exhalation, a high-velocity, low-amplitude force is delivered. Use caution that the patient does not hyperventilate during these procedures.

PRECAUTIONS:

• Do not perform if manipulation causes a change in sensation or pain to radiate down an extremity.

• Extreme caution should be used when performing these techniques if the patient is pregnant, reports a current history of corticosteroid use, or has excessive pain.

CONTRAINDICATIONS:

• Unhealed fracture

• History of joint or ligamentous laxity caused by trauma or systemic diseases

• Spondylolisthesis

• Acute joint inflammation/irritation

• Cauda equine symptoms

• HVT is contraindicated in persons with a history of osteoporosis or osteopenia.

Manipulation Technique to Increase Thoracic Spine Extension

Patient position: Prone with arms resting comfortably at patient's side (Fig. 16. 22) VIDEO 16.3 . Place a pillow under the thoracic region for increased patient comfort and to promote a neutral cervical-thoracic curve. Therapist position and hand placement: Stand on one side of the patient with your body facing toward the head of the patient. Place the distal phalanx of your second and third fingers on the transverse processes of the superior vertebral segment to be manipulated (Fig. 16.22 A). This is also referred to as the "V-spread technique." Place the hypothenar eminence of your other hand on top of the two-finger contact (Fig. 16.22 B).

Manipulation force: Apply an anterior glide. The contact points on the transverse processes serve as a point of reference. Your other hand exerts a force through the hypothenar eminence in an anterior direction.

Manipulation Technique to Increase Thoracic Spine Flexion

Patient position: Prone with arms resting comfortably at patient's side. Place a pillow under the thoracic region for increased patient comfort and to promote a neutral cervical-thoracic curve.

Therapist position and hand placement: Same as for thoracic extension except the V-spread contact is on the transverse processes of the inferior vertebral segment to be mobilized.

Manipulation force: Apply an anterior glide. The contact points on the transverse processes serve as a point of reference. The other hand exerts a force through the hypothenar eminence in an anterior direction. Modify your forces for pain modulation or to improve motion.

Manipulation to Increase Thoracic Spine Rotation

Patient position: Prone with arms resting comfortably at patient's side (Fig. 16.23) VIDEO 16.3 . Place a pillow under the thoracic region for increased patient comfort and to promote a neutral cervical-thoracic curve.

Therapist position and hand placement: Using the V-spread contact, place one finger on the superior transverse process and the second finger on the contralateral inferior transverse process to be mobilized. The finger placement follows the "Rule of the Lower Finger" (see Clinical Tip).

Manipulation force: Apply an anteriorly directed force against the transverse processes with the contralateral hand pressing through the contact fingers.

Pistol Thrust to Increase Thoracic Spine Mobility

Patient position: Supine with arms crossed (Fig. 16.24) VIDEO 16.4 .

Therapist position and hand placement: Stand at the patient's side facing toward his or her head. Roll the patient toward you and reach across the patient's body; contact the inferior vertebra of the three-joint complex to be manipulated using the "pistol grip" (Fig. 16.24 A and C). Once contact is achieved, passively return the patient to the supine position. To improve rotation, use the rule of the lower finger as described in the clinical tip above.

Manipulation force: Place your trunk directly over the segment to be manipulated. A cephalad distraction force is initiated with the patient's body weight at the segment to be manipulated; this is followed by a high-velocity, posterior force against the patient's crossed arms toward the table (Fig. 16.24 B).

Cross-Arm Thrust to Increase Thoracic Spine Mobility

Patient position: Prone with arms resting comfortably at patient's side (Fig. 16.25). Place a pillow under the thoracic region for increased patient comfort and to promote a neutral cervical-thoracic curve.

Therapist position and hand placement: Stand beside the patient. Cross your arms and place the pisiform (hypothenar eminence) of one hand on a left and one on a right transverse process of the segment to be manipulated. Modify transverse process contact to promote flexion, extension, or rotation by placing the pisiform on the superior, inferior, or "rule of the lower finger" transverse processes as described in the preceding sections.

Manipulation force: An anterior force is applied simultaneously by the hypothenar eminences. This may be used as either a manipulation or HVT intervention.

Fall Thrust to Increase Thoracic Spine Mobility

Patient position: Standing with arms crossed (Fig. 16.26) VIDEO 16.5 .

Therapist position and hand placement: Stand behind the patient and wrap your arms around the patient. Place a mobilization wedge or folded towel at the desired spinal level to direct the force to a specific thoracic segment. Grasp patient's elbows (left hand grasps patient's right elbow and right hand grasps left elbow). If unable to grasp the elbows, interlock your fingers in front of the patient.

Manipulation force: Lean backwards on your heels while applying an extension force on the patient's spine, then quickly drop down so your feet are flat on the floor.

Rib Manipulation for Expiratory Restriction

Patient position: Prone with arms resting comfortably at the patient's side or overhead (Fig. 16.27) VIDEO 16.6 . Place a pillow under the thoracic region for increased patient comfort and to promote a neutral cervical-thoracic curve.

Therapist position and hand placement: Stand beside the patient. The hypothenar eminence of your caudal facing hand is placed on the rib angle at the level of the hypomobility, and the rest of the hand relaxes on the patient's back. The other hand is placed on the opposite rib to stabilize the rib cage.

Manipulation force: During active patient expiration, exert a series of four to five progressive manipulations against the restricted rib in an anterior, caudal, and medial direction during the last half of the expiratory phase. Use caution that the patient does not hyperventilate.

Rib Manipulation for Inspiratory Restriction

Patient position: Prone with scapula protracted on the side of the rib restriction (Fig. 16.28). This can be accomplished by having the patient dangle the arm off the side of the treatment table. Place a pillow under the thoracic region for increased patient comfort and to promote a neutral cervical-thoracic curve.

Therapist position and hand placement: Stand on the side opposite the restriction; reach across the thorax with your inferior extremity and contact the pisiform or hypothenar eminence of your hand on the inferio-medial aspect at the angle of the rib to be manipulated. Stabilize your upper body with the contralateral hand leaning on the table.

Manipulation force: During patient exhalation, apply the force to remove all the slack from the costovertebral joint; continue with four to five progressive oscillations approximately half way through the inspiratory phase. Apply the force perpendicular to the rib angle (in an anterior, caudal, and medial direction). Use caution that the patient does not hyperventilate.

Elevated First Rib Manipulation

Patient position: Sitting in a firm chair with his or her back supported (Fig. 16. 29) VIDEO 16.7 . The head and neck are laterally flexed towards and rotated away from the side of restriction to stabilize the facets in the closed-pack position and relax the scalene muscle.

Alternate head/neck position: The head and cervical spine are rotated towards the side of restriction to bring the transverse process posterior and place the first costotransverse articulation at end-range stretched position.

Therapist position and hand placement: Stand behind the patient and stabilize the head against your thorax. Place the second MCP of your other hand on the first rib just lateral to the costotransverse joint.

Manipulation force: Exert the manipulation force or HVT through the rib in a caudal and medial direction during patient exhalation.

Manipulation Techniques to Increase Lumbar Spine Extension

Patient position: Prone (Fig. 16.30) VIDEO 16.8 . Place a pillow under the abdominal region for patient comfort and to provide a neutral lumbosacral curve.

Therapist position and hand placement: Place your pisiform (hypothenar eminence) over the spinous process. Relax the rest of your hand on the patient's back.

Anterior glide manipulation force: Push with your hypothenar eminence in an anterior direction. Align your trunk directly over the segment, so the force is directed downward and not at an angle.

Manipulation to Increase Lumbar Spine Rotation

Patient position: Prone (Fig. 16.31) VIDEO 16.8 . Place a pillow under the abdominal region for patient comfort and to provide a neutral lumbosacral curve.

Therapist position and hand placement: Place your pisiform (hypothenar eminence) over one transverse process on the side opposite of the direction of the motion you wish to facilitate (i.e., if wanting to promote left rotation, place your hypothenar eminence on the right transverse process). Relax the rest of your hand on the patient's back.

Anterior glide manipulation force: Push with your hypothenar eminence in an anterior and medial direction.

Manipulation to Increase Lumbar Intervertebral Side Bending

Patient position: Side-lying with the restricted side down (Fig. 16.32) VIDEO 16.9 . Position the patient as close to the edge of the bed as possible and flex the hips and knees to 90°.

Therapist position and hand placement: Stand facing the patient. Place the finger tip from your caudal hand on the superior spinous process to monitor motion. Passively rotate the patient's trunk backward to "take up the slack" until just before you feel the vertebral segment move. Now, place the finger tip of your cephlad hand on the superior spinous process to monitor motion. Flex both of the patient's legs (hips) until just before you feel the vertebral segment move. The patient's legs can then be supported either on the plinth or your thigh.

Manipulation force: Lift the patient's legs into hip rotation, causing the lumbar spine to side bend in the same direction as the lifted legs.

HVT Lumbar Roll to Increase Lumbar Rotation

Patient position: Side-lying with the restricted side up (Fig. 16.33) VIDEO 16.10 . Position the patient as close to the edge of the bed as possible and flex the hips and knees to 90°. Provide a pillow for the patient to hold that can act as a physical barrier.

Therapist position and hand placement: Stand facing the patient. Place the finger tips of your cephlad hand on the inferior spinous process to monitor motion. Move the patient's top leg into hip flexion until just before you feel the inferior vertebral segment move. Maintain the patient's hip flexion by stabilizing the leg between the therapist's body and the treatment table, and move your cephalad hand to the superior spinous process to monitor motion (Fig. 16.33 A).

Passively rotate the patient's trunk backward to "take up the slack" until just before you feel the superior vertebral segment move, and rest the forearm on the patient's torso. The therapist's torso should be directly over the segment to be manipulated (Fig. 16.33 B).

Manipulation force:

• Therapist exerts a downward rotational thrust toward the table with the cephalad forearm and hand while exerting a rotational force through the caudal forearm by pulling the patient's lower trunk toward your body (Fig. 16.33 B and C).

• Altnernative method is to use the caudal forearm and apply a rotational force through the patient's innominate. This technique (patient contact) is particularly useful if attempting to increase rotation at L5–S1.

SI Joint Manipulation Technique to Increase Sacral Nutation (Flexion)

Patient position: Prone (Fig. 16.34) VIDEO 16.11 . Place a pillow under the abdominal region for patient comfort and to provide a neutral lum-bosacral curve.

Therapist position and hand placement: Place your pisiform (hypothenar eminence) over the apex of the sacrum (S5) region. Relax the rest of your hand on the patient's sacrum.

Anterior glide manipulation force: Push with your hypothenar eminence in an anterior-inferior direction.

SI Joint Manipulation Technique to Increase Sacral Counternutation (Extension)

Patient position: Prone (Fig. 16.35) VIDEO 16.11. Place a pillow under the abdominal region for patient comfort and to provide a neutral lumbosacral curve.

Therapist position and hand placement: Place your pisiform (hypothenar eminence) over the sacral base (S1) region. Relax the rest of your hand on the patient's back.

Anterior glide manipulation force: Push with your hypothenar eminence in an anterior-inferior direction.

Posterior Rotation Manipulation to Innominate

Patient position: Supine with arms crossed over chest (Fig. 16.36) VIDEO 16.11 . Move the patient's trunk and legs toward the side of the restriction to create sidebending in the lumbar spine.

Therapist position and hand placement: Stand on the side opposite the restriction. Contact the patient's opposite ASIS with your caudal hand. With the cephalad, roll the patient's trunk toward you.

Manipulation force: Exert a progressive oscillation or HVT force posterior through the hand contact at the innominate.

Goals. To: (1) activate and develop neuromuscular control of deep segmental and global spinal stabilizing muscles to support the spine against external loading; (2) develop endurance and strength in the muscles of the axial skeleton for functional activities; and (3) develop control of balance in stable and unstable situations.

This section is divided into two main sections. The first section presents principles and techniques of stabilization exercises for the cervical and lumbar spinal regions with a subsection on motor control exercises for segmental muscle activation and a subsection on global muscle stabilization. The second section presents principles and techniques of general isometric, dynamic, and functional exercises for the neck and trunk.

Stabilization Training: Fundamental Techniques and Progressions

"Proximal stability for distal mobility," a well known phrase, is an underlying principle of intervention with therapeutic exercise. The primary functions of the muscles of the trunk are to provide stability, so upright posture can be maintained against a variety of forces that disturb balance and to provide a stable base, so the muscles of the extremities can execute their function efficiently and without undue stress to the spinal structures. Several studies have demonstrated altered or delayed neuromuscular recruitment patterns in the deep stabilizing muscles of the lumbar spine during active movement in individuals with low back pain.^21,24,25,44 Results of other studies have shown improved ability to recruit these muscles with specific training⁴³ and improved outcomes compared with individuals not receiving the training.^20,43,44 Studies have also demonstrated improved outcomes in patients with cervical pain and cervicogenic headaches with recruitment of the deep stabilizing musculature in the cervical spine in conjunction with total trunk stabilization.^30,37

The functions of the deep segmental musculature and the superficial global (multi-segmental) spinal musculature were identified and described in Chapter 14. Both muscle systems are necessary for spinal stability and function. Therefore, one of the primary areas of emphasis during rehabilitation after spinal problems is recruiting the segmental muscles and training them to respond along with the global musculature to various forces and demands imposed on the spine to improve coordination of their overall function. Activation of the stabilizing musculature is then reinforced when progressing to muscular endurance and strengthening exercises, when performing aerobic exercises, and when practicing functional activities throughout the rehabilitative process with the anticipation that muscle activation for stabilization will become automatic during all daily activities and functional challenges (Fig. 16.37).

Stabilization training follows the basic principles of learning motor control first by developing awareness of muscle contractions and spinal position, then by developing control in simple patterns and exercises, then progressing to complex exercises, and finally by demonstrating automatic maintenance of spinal stability and control in a progression of simple functional activities to complex and unplanned situations.⁵⁵ Many of the exercises can be used to accomplish more than one purpose; there is definite overlap with kinesthetic training, muscle performance, and functional training. The choice and progression of exercises described in each of the sections rely on clinical judgment of the patient's response and attainment of goals, not on a strict, time-based protocol or number of days from injury. The ability of the patient to control the spine in a neutral or nonstressful position is paramount for all the exercises.

There is considerably more research on muscle function and its stabilization action in the lumbar spine than the cervical spine. The cervical spine requires more mobility to position the head, yet relies on the thoracic and lumbar spinal regions to provide a base for stability and postural control. Even though there are unique anatomical considerations in the cervical spine, there is overlap between stabilization training for cervical and lumbar problems.

Guidelines for Stabilization Training

It is important to understand and use the principles and progression of stabilization training for effective instruction.^{6,41,51,52,53} The following guidelines are summarized in Box 16.2.

1. Kinesthetic training for awareness of safe motion and positions must precede stabilization training. The functional range and functional position in which symptoms are minimal or absent are used for stabilization exercises.⁴¹ When the condition is not acute, most people find the mid-range (the neutral position) to be their functional position. It is important to recognize that this position or range is not static; nor is it the same for every person. In addition, it may change as the tissues heal, nociceptive stimuli decrease, and flexibility improves.⁴¹

2. Activation of the deep segmental muscles of the trunk, specifically the transversus abdominis (TrA) and multifidus (Mf), is often delayed or absent in patients with back pain.^21,25,44 In addition, ultrasound imaging studies on individuals with unilateral low back pain have shown decreased activation of these deep muscles on the side of symptoms compared to the uninvolved side when performing voluntary contractions.⁵⁹

   Learning conscious activation of the deep segmental muscles without contracting the global trunk musculature is the first step in developing habitual activation for spinal stability in patients with pain related to poor spinal control and segmental instability. Once the individual learns correct activation of the segmental stabilizers using the "drawing-in" maneuver, this maneuver is used prior to all exercises and activities to develop the activation and stabilizing function and eventually automatic feedforward stabilization from the muscles.²⁶ A study involving 42 subjects demonstrated that it is possible to alter abdominal muscle activation consciously and automatically with specific exercises.⁴³

   In the cervical region, the deep cervical flexors, the longus colli and longus capitis, and the deep cervical and upper thoracic extensors are activated to stabilize the cervical spine in a neutral spinal position (axial extension with mild lordosis).

3. Extremity motions are added to the stabilization program to coordinate segmental muscle activity with the global stabilizing musculature. Loading via the extremities increases the stabilizing challenge to the musculature. The patient positions the spine in the neutral position (using pelvic tilt motions in the lumbar region and gentle head nodding in the cervical region), performs the drawing-in maneuver, and then begins moving one or several extremities while maintaining the neutral position. Extremity motions are performed within the tolerance of the trunk or neck muscles to control the neutral or functional position. This is called dynamic stabilization, because the stabilizing muscles in the spinal area must respond to the changing forces coming from the dynamic movement of the extremities. Exercises that require stabilization against transverse plane rotational forces on the pelvis more consistently activate the oblique abdominal and deep spinal stabilizers than sagittal plane resistive forces.⁵⁰

4. Increase muscular endurance and strength once control of the spinal position is established and the patient can activate the stabilizing muscles. Repetitions of extremity motions are increased, and resistance is applied to the extremities. The intent is to challenge the trunk muscles to stabilize against these increased forces yet stay within their tolerance and ability to control the spinal position. Repetitions also help develop habit; therefore, it is important to use careful instructions and provide feedback. Fatigue is determined by the inability of the trunk or neck muscles to stabilize the spine in its functional position or by increased pain. For example:

   • Begin at a resistance force that the patient can repeat for 30 to 60 seconds and maintain the neutral position of the spine; progress the repetitions to 3 minutes.

   • Progress by adding resistance to or increasing the lever arm of the extremities; initially, reduce the time and again progress to doing the new activity for 1 to 3 minutes.

   • Another way to develop endurance in the trunk muscles is to begin exercising at the most difficult level for that patient, then shift to simpler levels of resistance as fatigue begins in order to keep moving. It is important that the patient does not lose control of the functional position or experience increased symptoms.

5. Alternating isometric contractions between antagonists and rhythmic stabilization of the trunk muscles against manual resistance also enhance stabilizing contractions. When performed while sitting and standing, the alternating contractions and co-contractions also develop control of balance.

6. Transitional stabilization develops as the patient moves from one position to another in conjunction with extremity motions. This requires graded contractions and adjustments between the trunk flexors and extensors and requires greater awareness and concentration.^6,41 For example, any motion of the arms or legs away from the trunk tends to cause the spine to extend. The abdominals (trunk flexors) must contract to maintain control of the functional spinal position. This occurs, for example, when lifting a load from the floor to overhead. Then, as the arms or legs move anteriorly toward the center of gravity, the spine tends to flex, which requires the extensors to contract to maintain the functional position (as would occur when lowering a weight to the floor). Greater concentration on maintaining the functional spinal position is necessary when doing more advanced functional activities.

7. Perturbation (balance) training, exercising against destabilizing forces or on unstable surfaces, develops neuromuscular responses to improve balance.

Deep Segmental Muscle Activation and Training

The function of the deep musculature (TrA and Mf in the lumbar spine and longus colli and other deep musculature in the cervical spine) is described in Chapter 14, and the results of impaired function in these muscles are described in Chapter 15. Techniques for activation of the segmental musculature are described in this section.

Cervical Musculature

In the cervical region, the goal is to activate and control the muscles that control axial extension (cervical retraction). This requires capital flexion, slight flattening of the cervical lordosis, and flattening of the upper thoracic kyphosis (Fig. 16.38).

Deep Neck Flexors: Activation and Training

Patient position and procedure: Supine VIDEO 16.12 . For craniocervical flexion and gentle axial extension, teach the patient to perform slow, controlled nodding motions of the head on the upper cervical spine ("yes" motion). If the patient has a significant forward head posture, place a folded towel under the occipital area, so extension of the head on the neck does not occur. Facilitate the motion with manual cues to ensure the longus colli is contracting, or the sternocleidomastoid is at a relative state of rest. Once the patient is able to activate the motion, the Stabilizer^TM (or blood pressure cuff) may be used to monitor the amount of cervical flattening and measure the muscular endurance for holding the contraction (Fig. 16.39). The protocol for use of the Stabilizer^TM is summarized in Box 16.3.

Lower Cervical and Upper Thoracic Extensor Activation and Training

Patient position and procedure: Prone with forehead on the treatment table and arms at the sides. Have the patient lift the forehead off the treatment table, keeping the chin tucked and eyes focused on the table to maintain the neutral spinal position (reinforces the craniocervical flexion motion learned in the supine position). Lifting the head is a small motion (Fig. 16.40).

Progression

Once the patient learns to activate the deep musculature and assume the neutral posture in the cervical spine, practice throughout the day is encouraged in order to develop good postural control. Stabilization training is initiated by coordinating control of the neutral spinal position with upper extremity loading. The extremity motions are used to stimulate muscular endurance as well as strengthen the stabilizing musculature in the spine. These exercises are described in the next section 'Global Muscle Stabilization Exercises.'

Lumbar Musculature

Three techniques for abdominal muscle activation have been described and used in clinical practice: the drawing-in maneuver; abdominal bracing; and posterior pelvic tilt (Fig. 16.41). Each technique differs in the stabilization activity of the abdominal and multifidus muscles.⁴⁹ Studies have demonstrated that the drawing-in maneuver is more selective in co-activating the transversus abdominis and multifidus muscles than the abdominal bracing and posterior pelvic tilt techniques,^28,49 and that the drawing-in maneuver leads to improvement in feedforward postural strategies.⁶² The drawing-in maneuver also functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall. Because of this, the drawing-in maneuver is recommended for stabilization training; the other two methods are also described, primarily so the reader can recognize the differences.

Drawing-In Maneuver (Abdominal Hollowing Exercise) for Transverse Abdominis Activation

Patient positions: Training may be easiest in the quadruped position in order to use the effects of gravity on the abdominal wall VIDEO 16.13 . Hook-lying (with knees 70° to 90° and feet resting on an exercise mat), prone-lying, or semireclined positions may be used if more comfortable for the patient. It is important to progress training to sitting and standing as soon as possible.^38,40

Procedure: Teach the patient using demonstration, verbal cues, and tactile facilitation. Explain that the muscle encircles the trunk, and when activated, the waistline draws inward (see Fig. 16.41 A).

• Palpate the transversus abdominis (TrA) muscle just distal to the anterior superior iliac spine (ASIS) and lateral to the rectus abdominis (RA) (Fig. 16.42). When the internal oblique (IO) contracts, a bulge of the muscle is felt; when the TrA contracts, flat tension is felt. The goal is to activate the TrA with minimal or no contraction of the IO. This is a gentle contraction.

• Have the patient assume a neutral spinal position and attempt to maintain it while gently drawing in and hollowing the abdominal muscles.⁴⁷ Instruct the patient to breathe in, breath out, then gently draw the belly button in toward the spine to hollow out the abdominal region. When done properly, there are no substitute patterns; that is, there is minimal to no movement of the pelvis (posterior pelvic tilting), no flaring or depression of the lower ribs, no inspiration or lifting of the rib cage, no bulging out of the abdominal wall, and no increased pressure through the feet. Performing the drawing-in maneuver with the spine in a neutral position results in increased TrA response (measured as increased thickness in ultrasound imaging) compared to slouched sitting or slouched standing postures.⁴⁶

If a patient has difficulty activating the TrA, the following two feedback techniques have been shown to assist with learning.^17,48,49

• Pressure biofeedback for clinical testing and visual feedback. With the patient prone, the Stabilizer^TM (or blood pressure cuff) is placed horizontally under the abdomen (centered under the navel). Inflate the Stabilizer^TM to 70 mm Hg. Have the patient perform a drawing-in maneuver, as described above. A decrease of 6 to 10 mm Hg during the drawing-in maneuver (without substitutions) indicates proper activation of the deep abdominal muscles. The dial on the unit is large and easily read by the patient for immediate feedback.

• Biofeedback with surface electrodes. Surface electrodes placed over the rectus abdominis and external obliques (near its attachment on the eighth rib) may be used in conjunction with the inflatable cuff. There should be minimal to no activation of these muscles if the drawing-in maneuver is done correctly.

As with the cervical spine, the Stabilizer^TM can be used not only to train and reinforce activation of the TrA but also to measure control for a measured period of time as well as number of repetitions. The protocol is summarized in Box 16.4.

Abdominal Bracing

In contrast to the drawing-in maneuver, abdominal bracing occurs by setting the abdominals and actively flaring out laterally around the waist (see Fig. 16.41 B). There is no head or trunk flexion, no elevation of the lower ribs, no protrusion of the abdomen, and no pressure through the feet. The patient should be able to hold the braced position while breathing in a relaxed manner. This technique has been taught for a number of years as the method to stabilize the spine; it has been shown to activate the oblique abdominal muscles consistent with their global stabilization function.⁴⁹

Posterior Pelvic Tilt

Posterior pelvic tilt exercises (see Fig. 16.41 C) principally activate the rectus abdominis muscle, which is used primarily for dynamic trunk flexion activity. It is a superficial muscle that does not have segmental attachments; therefore, it is not emphasized in the training for stabilization.⁴⁹ Pelvic tilt exercises are used to teach awareness of the movement of the pelvis and lumbar spine as the patient explores his or her lumbar ROM to find the functional spinal range and the neutral position.

Multifidus Activation and Training

Patient position and procedure: Prone or side-lying VIDEO 16.14 . Place your palpating digits (thumbs or index fingers) immediately lateral to the spinous processes of the lumbar spine (Fig. 16.43).

• Palpate each spinal level so comparisons in the activation of the multifidus (Mf) muscle can be made between each segment as well as from side-to-side.

• Instruct the patient to "swell the muscle" out against your digits. Palpate for consistency of muscle contraction at each level.

• Facilitation techniques include using the drawing in maneuver and gently contracting the pelvic floor muscles (as in Kegel exercises, described in Chapter 24).

• In the side-lying position, facilitate by gently applying manual resistance to the thorax or pelvis to activate the rotation function of the Mf.

• The patient may be taught to self-palpate a Mf contraction in the following manner. Sit and rock the pelvis to find the neutral position; with the fingers or thumbs placed along the lumbar spinous processes, lean forward a couple degrees. The Mf is thus activated. Differentiate a Mf contraction from tension in the aponeurosis of the global erector spinae.

Progression

Once the patient learns to activate the deep segmental musculature, practice throughout the day is encouraged. Segmental muscle activation is then coordinated with stabilization training, using the global musculature and extremity loading. Extremity motions are added and used to stimulate muscle endurance as well as strengthen the trunk muscles. Global stabilization exercises are described in the next section.

Global Muscle Stabilization Exercises

Even though this section is divided into cervical and lumbar regions, many of the same exercises may be used for impairments in either region because of the functional relationships of the entire axial skeleton.

Stabilization Exercises for the Cervical Region

Stabilization with Progressive Limb Loading

In general, stabilization exercises begin in the recumbent position and progress to sitting, sitting on a large gym ball, standing with the back supported against a wall, and finally standing without support. For advanced training, exercises are progressed to standing on an unstable surface.

• Begin all exercises with gentle craniocervical nods and axial extension to the neutral spinal position to activate the deep segmental muscles as described in the previous section. During the early phases of training, if the patient has difficulty maintaining a neutral spinal position, a small towel roll may be placed under the neck for passive support.

• Initially, the only resistance load comes from simple upper extremity movements. When the patient can perform multiple repetitions of the upper extremity motions without losing control of the spinal position or causing an increase in symptoms, resistance is added with handheld weights or elastic resistance.

• The principles of muscle endurance and strengthening described in Chapter 6 are used to challenge the spinal stabilizing musculature.

• Table 16.3 summarizes limb-loading exercises that emphasize the flexor muscles, and Figure 16.44 illustrates the basic exercise progression in the supine position.

• Table 16.4 summarizes limb-loading exercises that emphasize the lower cervical/upper thoracic extensor muscles, and Figure 16.45 illustrates a basic exercise progression in the prone position. It is important to note that these exercises do not isolate the flexors or extensors, but the designation is primarily for emphasis due to the effects of gravity.

Variations and Progressions in the Stabilization Program

Remind the patient to find and maintain the neutral spinal position when doing these exercises.

• Extremity loading. During the early phases of training, limit shoulder flexion to 90° flexion and abduction. Once the patient can maintain stability and symptoms are not provoked, greater challenges occur with elevating the upper extremity full ROM. Unilateral and asymmetrical upper extremity motion require greater control than bilateral motion.

• External resistance. Tables 16.3 and 16.4 summarize progressions based on position changes. In addition, use of resistance loads (free weights, elastic resistance, or manual resistance) to any of the exercises adds to the stabilizing challenge. Even though external resistance applied through the extremities has the benefit of increasing strength in the extremity musculature, the primary goal is to increase the stabilizing response of the cervical musculature. Therefore, any loss of the neutral spinal posture or increase in cervical symptoms signals the need to decrease the intensity of the resistance force.

• Unstable surfaces. The application of external resistance while on an unstable surface, such as sitting on a large ball (Fig. 16.46 A), lying prone over a ball (Fig. 16.46 B), or standing supporting the ball between the head and the wall (Fig. 16.46 C), provides additional challenges to the muscles as they respond to perturbations. Many variations of these exercises can be used to challenge the stabilizing muscles so long as the patient is able to maintain control.

• Muscular endurance and strength. Determine the maximum level of resistance tolerated by the cervical-stabilizing musculature that does not reproduce symptoms. Decrease the intensity and have the patient exercise with multiple repetitions at that level (20 to 30 repetitions or for 1 minute). Resistance can then be added for strengthening (decrease the number of repetitions) at that level before progressing to endurance training at the next level.

Integration of Stabilization Exercises and Posture Training

Good postural alignment of the neck begins with the pelvis and lumbar spine and moves up to the scapular and thoracic regions. The thorax must be lifted up from the pelvis and scapula retracted in a comfortable position for the cervical spine to assume an efficient position of axial extension (cervical retraction). Therefore, begin with lumbopelvic control if necessary and develop thoracic extension and scapular retraction. While the patient is performing the extremity motions to develop stability, reinforce good scapulohumeral alignment. It is important to remember that strengthening alone does not correct faulty posture and, therefore, to utilize the reinforcement techniques and environmental adaptations that are discussed in Chapter 14.

Progression of Isometric and Dynamic Strengthening in Conjunction with Functional Activities

When the patient demonstrates good cervical stabilization and response to various upper extremity resistance changes, isometric and dynamic exercises are integrated into the program. These are described in the 'Isometric and Dynamic Exercise' section following this section.

Stabilization Exercises for the Lumbar Region

Once the patient learns to activate the deep segmental muscles in the lumbar region, explain that prior to each exercise the patient is to find the neutral spinal position, perform the drawing-in maneuver, and then maintain control while applying an exercise load with extremity motions. The drawing-in maneuver develops the pattern of setting the deep abdominal and multifidus muscles in a feedforward pattern and then trains their holding capacity in coordination with the global muscles.¹⁷

Stabilization with Progressive Limb Loading

Begin with the patient supine for greatest support, adding quadruped exercises when able. If the patient cannot control the position, pre-position him or her using pillows or supports (see Box 15.6).

• To improve the holding capacity of the stabilizing muscles, increase the amount of time the patient does the exercises. It is important that no exercise is continued if the patient cannot maintain the stable position. If the deep abdominals cannot stabilize, substitute patterns in the superficial muscles that override the deep muscle activation.

• The Stabilizer^TM Pressure Biofeedback unit (or blood pressure cuff) may be used for feedback during this early training (see Box 16.5 for guidelines).

• Table 16.5 summarizes basic limb-loading exercises in the supine position that emphasize the abdominal muscles, and Figures 16.47 and 16.48 illustrate the exercise progression.

• Table 16.6 summarizes limb-loading exercises in the quadruped and prone positions that emphasize the extensor muscles, and Figure 16.49 illustrates a basic exercise progression.

NOTE: The exercise progressions described in Table 16.5 are adapted from several research studies that investigated the reliability, validity, and sensitivity to change one exercise level with abdominal muscle stabilizing ability using lower-limb loading.^16,17,29 The exercise progressions described in Table 16.6 are adapted from electromyography (EMG) studies that documented extensor activity with limb loading in the quadruped and prone-lying positions.^5,39

Variations and Progressions in the Stabilization Exercise Program

For all exercises, reinforce the importance of first finding the neutral spine (cervical and lumbar regions), performing the drawing-in maneuver, and then maintaining the neutral spine while superimposing any extremity motions. It is critical to instruct the patient to stop the exercises (or decrease the intensity) as soon as loss of control of the stable spinal position is sensed. It is important not to progress the patient beyond what he or she is able to control in order to develop the proper muscle response. The emphasis is first on improving the static holding capacity (endurance) of the trunk muscles followed by strengthening. Endurance training of the trunk extensor muscles is related to decreased pain and improving function during the early stages of recovery in patients with subacute low back pain.¹⁰

• Emphasis on muscle endurance. Determine a level of exercise that the patient can perform for several repetitions while maintaining a stable spine in the neutral position. Have the patient exercise at that level with the goal of increasing the number of repetitions or the time. Once the patient can perform repetitions for 1 minute, add weights, decrease the repetitions, and emphasize strength. Progress to the next level of difficulty for muscular endurance.

• Use of external props. Use of the Stabilizer^TM pressure biofeedback unit to help the patient learn control while doing the abdominal stabilization exercises was described earlier (see Box 16.5). For exercises in the quadruped position, if the patient has difficulty controlling the trunk rotation, use a prop, such as a dowel rod, placed along the spine. Have the patient attempt to keep it balanced while performing the arm and leg exercises (Fig. 16.50). It may be helpful to cue the patient not to shift his or her weight as the extremity is moved—this is difficult to do but is effective in bringing in the stabilizing trunk muscles.

• Extremity loading. Boxes 16.5 and 16.6 identify a progression of exercises in supine and quadruped/prone positions with extremity loading. Initially, have the patient do the motions repetitively; then progress to alternating the extremities or moving all four extremities simultaneously (Fig. 16.51). This requires the stabilizing musculature to adjust to the shifting loads. Motions begin in the sagittal plane and then progress to the transverse plane and diagonal patterns (unilateral and bilateral), in which movement away from the midline adds a rotational component and increases the challenge to the stabilizing musculature.

• External resistance. Use weights, elastic resistance, or pulleys for strengthening. Several suggestions are illustrated in Figures 16.52, 16.53, and 16.54. Even though the extremities benefit from the exercises, the primary purpose is to improve performance in the stabilizing muscles of the trunk; therefore, when signs of fatigue occur, such as poor control of spinal stability (seen as movement of the pelvis or lumbar spine), reduce the intensity or stop the exercise and allow recovery.

• Position changes. Apply the extremity-loading exercises in the sitting (supported then unsupported), kneeling, and standing positions. Also, use modified bridging to challenge the stabilizing function of the trunk musculature. Exercises, such as wall slides and partial lunges and bridging with extremity motions, use the extremities and trunk during weight bearing and prepare the muscles for functional activities. These exercises are described in the final section under Functional Activities but also serve the purpose of challenging the stabilizing muscles.

• Unstable surfaces. Use a large gym ball, foam roller, or wobble board to challenge the patient's balance and develop the stabilizing musculature. With the ball, a variety of positions can be used, such as sitting upright on the ball with the feet on the floor (Fig. 16.55), lying supine with the trunk on the ball and feet on the floor (see Fig. 16.60 B) or with the feet on a low mat or wobble board. The foam roller can can be used with the patient supine (Fig. 16.56), kneeling, quadruped (with hands on one roller and knees on another), or standing. Use handheld weights or elastic or pulley resistance secured at various heights (see Fig. 16.54) to increase the challenge. VIDEOS 16.20 and 16.21

The quadratus lumborum has been identified as an important stabilizer of the spine in the frontal and transverse planes.³⁹ VIDEO 16.22 Strongest activation of this muscle occurs with the side propping (side plank) position. The external obliques are also activated in this position.³⁹

Patient position and procedure: Begin side-lying. Have the patient prop up on the elbow and then lift the pelvis off the mat, supporting the lower body with the lateral side of the knee on the downward side. The position can be maintained for an isometric hold or performed intermittently (Fig. 16.57 A). Progress by having the patient support the upper body with the hand (with the elbow extended) and lateral aspect of the foot on the downward side (Fig. 16.57 B). Arm and leg movements (without then with weights) are added to increase the challenge.

When the patient has developed control, endurance, and strength in the stabilizing muscles in weight-bearing and nonweight-bearing positions, dynamic trunk strengthening exercises are initiated at a low-intensity (see following section). The emphasis is on control and safety.

As the patient returns to his or her instrumental activities of daily living (IADLs) and limited work activities, instruct him or her to incorporate the deep segmental activation and global stabilization techniques into the activities.

Isometric and Dynamic Exercises

Isometric exercises may be considered stabilizing exercises, as there is little or no movement of the spinal segments. They are included in this section with dynamic exercises, however, because of the method of application of the resistive force; that is, the resistive force is applied directly to the axial skeleton rather than through limb loading, as described in the spinal stabilization section. The decision to use the isometric exercises described in this section must be based on the goals of intervention. The exercises may be combined with the stabilization exercises in a home exercise program.

Dynamic exercises with spinal movement are introduced into the patient's exercise program when the patient demonstrates effective segmental and global stabilization techniques and has developed endurance in the stabilizing musculature. Dynamic exercises should not be a substitute for stabilization exercises. Because of the load imposed on the spine, they may exacerbate the patient's symptoms if introduced prior to effective stabilization and control. They are important in the total rehabilitation of the individual with neck, thoracic, or low back pain, as dynamic muscle endurance and strength is required for many daily activities as well as manual labor and athletic performance.

Exercises for the Cervical Region

PRECAUTION: Use of external weights via a cable or pulley system applied directly to the head are contraindicated for cervical strength training due to the compressive loading on the spine and the potential loss of control during the exercise.

Isometric Exercises: Self-Resistance

The intensity of the isometric exercises can range from low to high, depending on the patient's symptoms and tolerance. Patient position and procedure: Sitting.

• Flexion. Have the patient place both hands on the forehead and press the forehead into the palms in a nodding fashion while not moving (Fig. 16.58 A).

• Side bending. Have the patient press one hand against the side of the head and attempt to side bend, as if trying to bring the ear toward the shoulder but not allowing motion.

• Axial extension. Have the patient press the back of the head into both hands, which are placed in the back, near the top of the head.

• Rotation. Have the patient press one hand against the region just superior and lateral to the eye and attempt to turn the head to look over the shoulder without allowing motion.

Isometric Resistance Activities

Patient position and procedure: Standing with a basketball-sized inflatable ball between the forehead and a wall. Have the patient keep the chin tucked and not go into a forward-head posture. The patient maintains the functional position while superimposing arm motions. Progress by adding weights to the arm motions. (See Fig. 16.46 C)

Dynamic Cervical Flexion

Patient position and procedure: Supine. If the patient cannot tuck the chin and curl the neck to lift the head off the mat, begin with the patient on a slant board or large wedge-shaped bolster under the thorax and head to reduce the effects of gravity (Fig. 16.59). Have the patient practice tucking the chin and curling the head up. Use assistance until the correct pattern is learned. Progress by decreasing the angle of the board or wedge and then adding manual resistance if the patient does not substitute with the SCM.

Manual Resistance: Cervical Muscles

Patient position and procedures: Supine. Stand at the head end of the treatment table, supporting the patient's head for each exercise.

• Place one hand on the patient's head to resist opposite the motion. Do not resist against the mandible lest force be transmitted to the temporomandibular joint. Resistance is given to isolated muscle actions or to general ROMs, whichever best gains muscle balance and function.

• Isometric resistance can be applied with the head in any desired position before applying resistance. Avoid jerking the neck when applying or releasing the resistance by gradually building up the intensity, telling the patient to match your resistance, holding, and then gradually releasing and asking the patient to relax.

Intermediate and Advanced Training

As the patient progresses in the rehabilitation program, greater challenges to the musculature to stabilize and control motion are emphasized, especially for those individuals returning to work, sports, or recreational activities that place greater demands on the cervical structures.

• Patient position and procedure: Standing with a basketball-sized inflatable ball between the head and the wall. Have the patient roll the ball along the wall, using the head. This requires the patient to turn the body as he or she walks along.

• Patient position and procedure: Sitting on a large gym ball. Have the patient walk the feet forward so the ball rolls up the back and the thorax is resting on the ball (Fig. 16.60 A and B). The head and neck are maintained in neutral position, and the cervical flexors are emphasized. Have the patient then walk the ball farther, so it is under the head. The extensors are now emphasized (Fig. 16.60 C). The patient walks the feet forward and backward, alternating stabilization between the flexors and extensors. Progress to advanced training by adding arm motions and then arm motions with weights in each of the positions.

NOTE: This activity requires considerable strength in the cervical extensors to support the body weight and should be performed only with advanced training with patients who have been properly progressed to tolerate the resistance.

Design exercises that simulate patient-specific functional activities. Identify what activities stress that individual's neck and have the patient practice modifications of those activities with the spine kept in neutral position. Include pushing, pulling, reaching, and lifting (see the 'Functional Training' section later in this chapter). Challenge the patient with increased repetitions and weight and by using patterns that replicate functional demands.

Exercises for the Thoracic and Lumbar Regions

Alternating Isometric Contractions and Rhythmic Stabilization

Patient positions and procedures: Begin with the patient supine in the most stable position (Fig. 16.61) VIDEO 16.23 . Progress to sitting on a stable surface, sitting on an unstable surface such as a large gym ball, kneeling, and then standing. Sitting, kneeling, and standing require stabilizing action in the hip, knee, and ankle musculature, respectively, as well as the spinal muscles. Apply resistance directly against the patient's shoulders or pelvis, against a rod that is held by the patient (as in Fig. 16.61), or against the patient's outstretched arms.

• Have the patient find the neutral spine position and then activate the stabilizing muscles with the drawing-in maneuver prior to applying the resistive force. Then instruct the patient to "meet my resistance" while applying a force to stimulate isometric contractions. Apply the resistance in alternating directions at a controlled speed while the patient learns to maintain a steady position.

• Initially, provide verbal cues, such as "hold against my resistance, but do not overpower me. Feel your abdominal muscles contracting. Now, I'm pulling in the opposite direction. Match the resistance and feel your back muscles contracting."

• Progress by shifting the directions of resistance without the verbal cues and then by increasing the speed and force.

• Begin with alternating resistance in the sagittal plane; progress to side-to-side and then transverse plane resistance. Isometric resistance to trunk rotation (transverse plane resistance) has been shown to be the most effective in stimulating the oblique abdominals, transversus abdominis, and deep spinal extensor muscles.⁵⁰

• Alternating resistance to pelvic rotation can also be done by having the patient assume a modified bridge position. Apply resistance directly to the pelvis to stimulate rotation while the patient isometrically holds the pelvis and spine in a stable position.

Dynamic Strengthening: Abdominal Muscles

NOTE: Dynamic exercises of the trunk musculature are not initiated until late during the rehabilitation process and not until after the patient has learned to activate the drawing-in maneuver automatically for stabilization in all functional activities.

No one abdominal exercise challenges all of the abdominal muscles³⁹; therefore, a variety of exercises should be included in the patient's exercise program to include the entire region.

Trunk Flexion (Abdominals): Supine

Patient position and procedures: Supine or hook-lying with the lumbar spine neutral. McGill³⁹ suggested supporting the low back with the hands to maintain slight lordosis. The spine should not be allowed to go into an increased lordosis during the exercise—this indicates weakness of the abdominals and consequently lifting of the trunk occurs from hip flexor action only.³² When training the abdominals, curl-up exercises should be performed at a slow, controlled rate to activate the stabilizing function of the abdominals.⁶⁵

PRECAUTIONS: If a patient experiences pain or increased radicular symptoms with trunk flexion, these exercises should not be done. Use the stabilization exercises, as described in the previous section, with the spine maintained in a neutral position (slight lordosis).

Curl-ups. First, instruct the patient to perform the drawing-in maneuver to cause a stabilizing contraction of the abdominal muscles⁶¹ (see section on 'Stabilization Training: Core Muscle Activation') and then lift the head. Progress by lifting the shoulders until the scapulae and thorax clear the mat, keeping the arms horizontal (Fig. 16.62). A full sit-up is not necessary, because once the thorax clears the mat, the rest of the motion is performed by the hip flexor muscles.

• Further progress the difficulty of the curl-up by having the patient change the arm position from horizontal to folded across the chest and then to behind the head; then by holding a weight or medicine ball. The weight is held with the shoulders at 90°flexion

Curl-downs. If the patient is unable to perform the curl-up, begin with curl-downs by having the patient start in the hook-sitting or long-sitting position and lower the trunk only to the point at which he or she can maintain a flat low back and then return to the sitting position.

• Once the patient can curl-down full range, reverse and perform a curl-up.

Diagonal curl-ups. Have the patient reach one hand toward the outside of the opposite knee while curling up; then alternate. Reverse the muscle action by bringing one knee up toward the opposite shoulder; then repeat with the other knee. Diagonal exercises emphasize the oblique muscles.

Curl-ups on an unstable surface. Progress the above curl-up exercises on an unstable surface, such as a large gym ball (Fig. 16.63), foam roller, or a biomechanical ankle platform system (BAPS) board.

Double knee-to-chest. To emphasize the lower rectus abdominis and oblique muscles, have the patient set a posterior pelvic tilt, bring both knees to the chest, and return. Progress the difficulty by decreasing the angle of hip and knee flexion (Fig. 16.64).

Pelvic lifts. Have the patient begin with the hips at 90° and the knees extended; then lift the buttocks upward off the mat (small motion). The feet move upward toward the ceiling (Fig. 16.65). The patient should not push against the mat with the hands.

Bilateral straight-leg raising. Have the patient begin with legs extended; then perform a posterior pelvic tilt followed by flexing both hips, keeping the knees extended. If the pelvis and spine cannot be kept stable, the knees should be flexed to a degree that allows control. If the hips are abducted before initiating this exercise, greater challenge is placed on the oblique abdominal muscles.

Bilateral straight-leg lowering. Bilateral straight-leg lowering can be performed if the bilateral SLR is difficult. Have the patient begin with the hips at 90° and knees extended; then, lower the extremities as far as possible while maintaining stability in the lumbar spine (should not increase the lordosis), followed by raising the legs back to 90°. See 'Precaution' under the bilateral SLR exercise.

PRECAUTIONS:

• The strong pull of the psoas major causes shear forces on the lumbar vertebrae. Also, the bilateral straight-leg raising and lowering exercises cause increased spinal compression loads.

• If there is any low-back pain or discomfort, especially with spinal hypermobility or instability, the bilateral straight-leg raising and lowering exercises should not be performed even if the abdominals are strong enough to maintain a posterior pelvic tilt.

• Be sure the patients avoid holding their breath (valsalva maneuver) as they may try to use their diaphragm to provide the stabilization.

Trunk Flexion (Abdominals): Sitting or Standing

Patient position and procedures: Sitting or standing. Pulleys or elastic material are secured at shoulder level behind the patient. Progress the resistance as the patient's abdominal strength increases.

• Have the patient hold the handles or ends of the elastic material with each hand and then flex the trunk, with emphasis on bringing the rib cage down toward the pubic bone and performing a posterior pelvic tilt (Fig. 16.66).

• Have the patient perform diagonal motions by bringing one arm down toward the opposite knee with emphasis on moving the rib cage down toward the opposite side of the pelvis. Repeat the diagonal motion in the opposite direction.

Dynamic Strengthening: Erector Spinae and Multifidus Muscles

Extension Exercises in Prone or Quadruped Position

Resistance can be applied to any of the following recumbent exercises by having the patient hold weights in the hands or by strapping weights around the patient's legs.

PRECAUTIONS: Extension exercises in the prone position are performed at the end of the ROM in spinal extension and therefore may not be appropriate for individuals with symptoms from conditions such as arthritis, spondylolisthesis, or nerve root compression. Patients with spondylosis or other flexion bias conditions or patients who develop symptoms under loaded conditions (e.g., with disc lesions) may experience increased symptoms and therefore should not do dynamic end-range extension exercises. If symptoms occur, modify the positioning toward more neutral spinal positions, such as the quadruped position, and emphasize stabilization with isometric holds rather than moving into full extension (see Figs. 16.49 A through D, 16.50, and 16.54).

Thoracic elevation. Begin with the arms at the sides, progress to behind the head or reaching overhead as strength improves. Have the patient tuck in the chin and lift the head and thorax. The lower extremities must be stabilized (Fig. 16.67).

Leg lifts. Initially, have the patient lift only one leg, alternate with the other leg, and, finally, lift both legs and extend the spine. (See Fig 16.28 E through G.) Stabilize the thorax by having the patient hold onto the side of the treatment table.

"Superman." Progress the extension exercises by having the patient lift both upper and lower extremities simultaneously (Fig. 16.68).

Variations. Patient positioned prone on a large gym ball; combine spinal extension with UE and/or LE resistance, similar to exercises described in the stabilization exercise section (see Fig. 16.46 B).

Extension Exercises Sitting or Standing

Elastic resistance or weighted pulleys. Secure pulleys or elastic resistance in front of the patient at shoulder level. Have the patient hold onto the ends of the material or handles and extend the spine (Fig. 16.69).

For trunk rotation, use a pulley or elastic resistance secured under the foot or to a stable object opposite the side being exercised. Have the patient pull against the resistance, extending and rotating the back. Change the angle of pull of the resistance to recreate functional patterns specific to the patient's needs (Fig. 16.70).

Trunk Side Bending (Lateral Abdominals, Erector Spinae, Quadratus Lumborum)

Trunk side-bending exercises are used for general strengthening of the muscles that side bend the trunk.

Side-bending exercises are also used if there is scoliosis, although exercise alone has not been shown to halt or change the progression of a structural scoliosis curve. Exercise in conjunction with other methods of correction, such as bracing, is often employed.⁸ When there is a lateral curve, the muscles on the convex side are usually stretched and weakened. The following exercises are described for use as strengthening exercises on the side of the convexity, although they may be used bilaterally for symmetrical strengthening. Stabilization exercises for spinal control, as previously described, may be beneficial for strengthening and conditioning when there is scoliosis.

• Patient position and procedure: Standing. Place elastic resistance under the foot or have the patient hold a weight in the hand on the side of the concavity; then have him or her side bend the trunk in the opposite direction.

• Patient position and procedure: Side-lying on the concave side of the curve with the apex at the edge of the table or mat so the thorax is lowered. If you have access to a split table with one end that can be lowered, begin with the apex of the curve at the bend of the table. Have the patient place the lower arm folded across the chest and upper arm along the side of the body and side bend the trunk up against gravity. Progress by having the patient clasp both hands behind the head (Fig. 16.71). Stabilization of the pelvis and lower extremities must be provided.

Goal. To develop cardiopulmonary fitness for overall endurance and well-being.

Aerobic conditioning exercises provide many benefits for the patient with spinal symptoms. The activity not only improves cardiopulmonary endurance but stimulates feelings of well-being and relief of symptoms. Chapter 7 describes cardiopulmonary conditioning principles and procedures. Specific precautions and suggestions for medical conditions are also explained. For patients recovering from spinal injuries, surgery, or postural dysfunction, aerobic exercises may be initiated once signs of inflammation no longer exist. Begin with low to moderate intensity and work with the patient to choose activities that do not place added stress on the recovering spinal structures. If a particular spinal bias has been identified (see Chapter 15), choose aerobic exercises that emphasize that spinal bias. A brief summary of the principles is reviewed in Box 16.6. Guidelines for safe application of common conditioning exercises when there are spinal impairments are described in this section.

Common Aerobic Exercises and Effects on the Spine

Some aerobic exercises place the spine in end-range positions. They are reviewed so the reader understands why some activities may be inappropriate for patients with specific conditions. If modifications are possible, they should be considered.

Cycling

Road bikes place the thoracolumbar spine in flexion and the upper cervical spine in hyperextension. Use this exercise for patients who have a flexion bias in the lumbar region so long as there are no upper cervical symptoms. Modifications include using a bike that positions the body in a more upright posture, such as a mountain bike or hybrid bike. Many stationary bikes also position the individual in upright postures and therefore are less likely to precipitate cervical problems.

Walking and Running

The upright posture emphasizes normal spinal curves, and lumbar extension is emphasized with walking and running (terminal stance). Emphasize the importance of identifying the neutral spine, activating the drawing-in maneuver, and stabilizing the spine while walking or running. Because conscious control is not possible during the entire exercise time, coach the patient to check his or her posture and muscle control frequently, such as each time he or she crosses an intersection or passes another individual or if symptoms develop in the spinal region. Walking or running with the cervical spine in retraction (axial extension) and the scapulae comfortably adducted, along with a rhythmic arm swing, reinforces cervical stabilization. Easy access to treadmills, tracks, or roads and trails makes these activities popular. Running is a high-impact activity and may not be tolerated by individuals with intervertebral disc lesions or degenerative joint conditions.

Stair Climbing

Commercial devices that replicate stepping with various grades of resistance are used for strengthening and aerobic conditioning. Regular steps can also be used for aerobic conditioning. This activity requires pelvic control of the reciprocating lower extremities, because lifting the leg on one side emphasizes spinal flexion while the contralateral lower extremity and spine are extending. Coach the patient to maintain the neutral spine with the stabilizing muscles against the rotational forces.

Cross-Country Skiing and Ski Machines

Cross-country skiing, whether out in the cold or on a commercial machine, is a high-intensity aerobic activity. The kicking motion that accompanies the backward motion of the leg emphasizes spinal extension. It is important to coach the patient to maintain the neutral spine and contract the stabilizing abdominal muscles.

Swimming

Breast stroke. The breaststroke emphasizes extension in the cervical and lumbar spinal regions when taking a breath. Coach the patient not to extend the neck full range but to keep it neutral and lift the head out of the water as a "solid" unit with the thorax just enough to clear the mouth for breath.

Freestyle. The freestyle stroke may exacerbate cervical problems because of the repetitive cervical rotation while taking a breath; this stroke also emphasizes lumbar extension with the flutter kick. Teach the patient to breathe using a "log-roll" technique in which the whole body rolls toward one side while breathing and then rolls back to the face-down position for the stroke. This requires good spinal stabilization.

Backstroke. The backstroke emphasizes spinal extension via kicking the lower extremities and the arm motions.

Butterfly stroke. The butterfly stroke moves the spine through a full ROM; emphasis is placed on controlling the range with the stabilizing muscles.

Upper Body Ergometers

Ergometry machines provide upper extremity resistance and can also be used for aerobic training. Forward motions emphasize spinal flexion and shoulder girdle protraction; backward motions emphasize spinal extension and shoulder girdle retraction. Coach the patient to assume the neutral spinal posture and use the stabilizing muscles prior to and during the use of the ergometer to enhance postural responses. If the machine can be used standing, progression to the standing position stimulates a total body response.

Step Aerobics and Aerobic Dancing

Stepping is similar to using stairs or a stair machine except for the jumping and bouncing that is usually added to the more advanced step aerobics programs.

Dancing moves take on many forms, and classes are taught that address various fitness levels and age groups. If possible, review safe movement patterns and help the patient recognize the safe limits of his or her spinal range and abilities.

"Latest Popular Craze"

People like variety and may be attracted to charismatic and energetic figures who demonstrate "new" workout techniques and routines or new exercise machines. Patients may ask for advice as to the value of the activities and techniques. Knowledge and skill in analyzing the biomechanics of the activity and the forces that are imposed through the spine should be used to provide advice about exercise safety. End-of-range postures and high-velocity stresses (such as vigorous kicking and ballistic motions) may be damaging to vulnerable tissues in the spine and should not be attempted by patients recovering from spinal problems.

Goal. To progress to independence safely.

NOTE: Achieving the maximum level of independence underlies all the goals of therapeutic exercise. The patient develops segmental and global spinal stability; develops flexibility, muscle endurance, and strength; learns how exercise and posture correction relieve stress; and develops cardiopulmonary endurance—all to be able to function safely in daily activities, including work, recreation, and athletic pursuits.

Early Functional Training: Fundamental Techniques

Early functional training consists of teaching basic maneuvers needed for ADL, such as safely rolling over, moving from lying down to sitting (and reverse), and going from sitting to standing (and reverse). These techniques follow the early kinesthetic training instruction in which the patient learns to find his or her neutral spine and experiences the effect that simple arm and leg motions have on the spine, as well as early muscle performance training in which the patient learns how to activate the core musculature for segmental stabilization. If the examination reveals problems with basic ADL activities, the following are included in the early training program.

Rolling. Rolling with a neutral spine requires that the patient first find the neutral spine, perform the drawing-in maneuver, and then roll the trunk as a unit.

• It may be helpful to suggest that the patient "imagine a solid rod connecting the shoulders and pelvis so as not to twist" or suggest that he or she "roll like a log."

• Encourage the patient to use the arms and top leg to assist the roll.

Supine to sit/sit to lying down. Have the patient use the log roll maneuver (as described above) to roll from supine to side-lying while simultaneously flexing the hips and knees and pushing up with the arms.

• Help the patient focus on stabilizing the trunk with commands such as "push up your trunk as if it is a board; do not allow it to twist or bend."

• The reverse is practiced by coaching the patient to lower to the side-lying position as a unit first onto the elbow and then shoulder. Once down, the patient can roll to supine or prone-lying using the log-roll technique.

Sit to stand/stand to sit. The patient's level of function dictates how much assistance from the upper extremities is needed to accomplish "sit to stand" or "stand to sit." If the hip and knee extensors are not strong enough to elevate the body, the patient requires a chair with armrests, so there is some leverage for pushing up; alternatively, a firm seat or elevated seat may be necessary.

• To use the stable spine technique, instruct the patient to find the neutral spine by rolling the pelvis forward and backward, activate the drawing-in maneuver, and then bend forward at the hips while maintaining the neutral spine position.

• Help the patient focus on the hip motion while keeping the spine "solid like a board." The reverse is also practiced.

In and out of a car. Getting in and out of a car is often symptom-provoking for patients with low back or sacroiliac joint pain. Once sit-to-stand can be safely performed, have the patient practice the following.

• Approach the open car door and seat with the back toward the seat; stabilize the spine in its neutral position with the drawing-in maneuver; then bend at the hips and sit down.

• Once seated, flex both hips and knees and pivot the whole body around as a unit, maintaining a stable spine.

• When exiting a car, keep both knees together and pivot the legs and trunk outward as a unit. Once the feet are on the ground, bend at the hips and elevate the trunk as a unit.

Walking. For some patients, walking may provoke symptoms.

• Remind the patient to use the neutral spine and drawing-in maneuvers to stabilize the spine while walking.

• It is not possible to maintain conscious control for long, so remind the patient to check the spinal posture and reactivate the drawing-in maneuver whenever the symptoms recur.

Preparation for Functional Activities: Basic Exercise Techniques

Once the patient has learned to manage his or her symptoms and the symptoms of inflammation diminish, exercises are initiated that prepare the extremities and trunk for functional activities, such as safely lifting, carrying, pushing, pulling, and reaching in various directions. In the subacute or controlled motion phase of rehabilitation, emphasis is placed on strengthening the extremities in functional patterns while maintaining a stable spine. The patient should be able to perform IADLs and limited work activities at this stage. Evaluate the patient's performance and modify what he or she is doing to include safe spinal postures and correct stabilization. Use the activities in this section to prepare for or advance the patient's function.

Many of the strengthening exercises described in the extremity chapters are appropriate to use in preparation for functional training. With postural problems and recovery from back or neck injuries, it is critical to emphasize the neutral (functional) spinal posture before and during total body exercises. Many of the stabilization and movement patterns described earlier in this chapter can also be progressed in intensity, repetition, speed, and coordination to prepare for return to functional activities.

Weight-Bearing Exercises

Modified Bridging Exercises

Modified bridging exercises require stabilization with the trunk flexor and extensor muscles in conjunction with strengthening the gluteus maximus and quadriceps muscles in preparation for lifting activities. The abdominals function with the gluteus maximus to control the pelvic tilt, and the lumbar extensors stabilize the spine against the pull of the gluteus maximus.

Patient position and procedures: Begin with the patient hook-lying. Have the patient concentrate on maintaining the neutral spinal position while raising and lowering the pelvis (flexing and extending at the hips) (see Fig. 20.28). Hold the bridge for isometric control.

• Alternate arm motions; progress by adding weights to the hands.

• Alternate lifting one foot and then the other by marching in place (Fig. 16.72 A); progress by extending the knee as each leg is lifted. When the patient tolerates greater resistance, add ankle weights and coordinate with arm motions (Fig. 16.72 B).

• Abduct and adduct the thighs without letting the pelvis sag. Progress by placing the feet on a stool, chair, or large gym ball and repeating the bridging activities, or by placing the large gym ball under the shoulder/neck region with feet on the floor.

Push-Ups with Trunk Stabilization

Push-ups use the body weight to strengthen the triceps and shoulder girdle musculature in preparation for pushing activities. The trunk musculature must stabilize against the pull of the shoulder girdle musculature as well as control the neutral spinal position as the body is raised and lowered.

Patient positions and procedures: Standing facing a wall or prone-lying with hands placed against the wall or floor in front of the shoulders. Remind the patient to find and maintain the neutral spinal position while performing the exercise.

• These exercises may begin as wall push-ups if the patient is not strong enough to push up from the floor.

• Prone-lying on the floor, the patient may push up with the pivot point being the knees or may perform full body push-ups with the pivot point being the feet.

• To challenge the patient on an unstable surface, he or she begins prone on a large gym ball. Have the patient walk forward with the hands on the floor until just the thighs are supported by the ball, maintain a stable spinal posture, and perform push-ups with the arms. To progress, walk out farther with the hands until just the legs are supported by the ball (Fig. 16.73).

Wall Slides

Wall slides develop strength in the hip and knee extensor muscles to prepare the lower extremities for squatting activities and training in safe body mechanics.

Patient position and procedure: Standing with the back to a wall and the spine held in its neutral position. Place a towel behind the back, so it slides easier along the wall. The exercise is more challenging if a large gym ball is placed between the back and the wall (Fig. 16.74). Have the patient slide his or her back down the wall into a partial squat and hold the position for isometric strengthening of the hip and knee extensors or move up and down for concentric/eccentric strengthening.

• Superimpose arm motions such as alternating or bilateral shoulder flexion/extension.

• Progress strengthening by incorporating single leg movements with marching steps or alternate knee extension.

• Use handheld weights to add resistance for upper and lower extremity strengthening.

Partial Lunges, Partial Squats, and Steps

Partial lunges and squats are described in Chapters 20 and 21. They are beneficial for strengthening total body movement in preparation for learning body mechanics. If necessary, begin by having the patient balance by holding onto the side of a treatment table or other stable object and then progress to balancing with a cane (see Fig. 20.32). Once able to perform multiple repetitions without holding on, add weights to the upper extremities for resistance.

• Add arm motions that are synchronized with the leg motions, such as reaching forward and downward to develop coordination and control.

• Progress to lunging onto an unstable surface and return upright.

• Add step-up/step-down activities, beginning with a low step and progressing the height.

Walking Against Resistance

Secure a weighted pulley or elastic resistance around the patient's pelvis with a belt, or the patient can hold the handles. Have the patient walk forward, backward, or diagonally against the resistive force. Emphasis is placed on spinal control (see Fig. 23.34).

Progress by having the patient push and pull weighted objects, such as a cart or a box on a table. Place emphasis on maintaining a stable spinal position while the extremities are loaded (see Figs. 17.58, 18.21 A, 23.18, and 23.36).

Transitional Stabilization Exercises

Exercises that cause movement into spinal flexion and then extension (and vice versa) challenge the patient to control the neutral spine position. The patient learns to stabilize the spine against alternating trunk and extremity motions.

Quadruped Forward/Backward Shifting

Patient position and procedure: Quadruped. Have the patient rock back to rest the buttocks on the heels; then shift the body forward onto the hands in the press-up position. The patient concentrates on controlling the pelvis in its neutral position rather than allowing full spinal flexion when shifting toward the heels or full spinal extension when shifting forward toward the press-up position.

Squatting and Reaching

Patient position and procedure: Begin standing. Have the patient reach downward while partially squatting. The tendency is for the spine to flex, so have the patient concentrate on maintaining a neutral spinal position with the spinal extensors. The patient then stands up and reaches overhead. This causes the spine to extend, so have the patient concentrate on using the trunk flexors to stabilize in the neutral position. Progress by lifting and reaching with weights while controlling the neutral posture of the spine.

Shifting Weight and Turning

Have the patient practice shifting weight forward/backward and side-to-side while maintaining the neutral spinal position and absorbing the forces with the hip and knee muscles. Practice turning using small steps and rotating at the hips rather than the back. Instruct the patient to imagine two rigid poles connecting each shoulder to each hip that do not allow the spine to twist. Even though some movement in the spine occurs, the activity helps the patient focus on a stable spine rather than rotating full range. Progress by using weights and having the patient lift, turn, and then place the weight at a new location.

Body Mechanics and Environmental Adaptations

Principles of Body Mechanics: Instruction and Training

When teaching safe body mechanics, it is advisable not to overwhelm the patient with too many instructions. Most people "know" they are to lift with their legs rather than their back, but they still have faulty techniques. Initiate training by suggesting that the patient find his or her neutral spine, perform the drawing-in maneuver, and then lift. Observe the technique they use and suggest modifications if needed. Squatting is often taught as the preferred method, yet not all patients are able to squat if they have impairments, such as knee pain or weakness. Under some circumstances, an individual may be more stable lifting with a lunge technique rather than the squat technique.

Lumbar Spine Position

The position of the lumbar spine, whether it is flexed, extended, or in mid-range, raises several issues. Of the three postures, lifting with a neutral spinal posture provides greater stability of the spine¹⁸ and uses both the ligamentous and muscular system for stabilization and control.⁵⁷ After a back injury, the preferred lifting posture may have to be adapted, depending on the type of injury and the response of the tissues when stressed.⁵⁷

Spinal flexion. When lifting with a flexed lumbar spine (posterior pelvic tilt), support for the spine is primarily from inert structures (ligaments, lumbodorsal fasciae, posterior annulus fibrosus, and facets); there is little muscle activity.

• Flexion occurs when stooping to the floor. Some have suggested that it may also be the posture of choice for a patient who has injured the back muscles, because the muscles are "quiet" when the spine is in flexion.⁵⁷

• Lifting with the lumbar spine in flexion may pose some problems. When lifting slowly with a flexed spine, the load is maintained on the ligaments, and creep of the inert tissues occurs; this increases the chance of injury if the tissue is already weakened. In addition, with the muscles lengthened and relaxed, they may be at an unfavorable length-tension relationship to respond quickly with appropriate force to resist a sudden change in load. There is greater chance of ligamentous strain when a person lifts with a flexed spine.²⁸

Spinal extension. When lifting with an extended (lordotic) lumbar spine, the muscles supporting the spine are more active than when flexed, which increases the compressive forces on the disc. Also, the facets are approximated (close-pack position). This posture relieves stress on the ligaments, but for an individual whose back muscles are in poor condition and fatigue quickly, this posture may jeopardize the spine when repeated lifts are performed, because the ligaments are not providing support.⁵⁷

Load Position

Reinforce the concept of lifting and carrying objects as close to the center of gravity as possible.

• Have the patient practice carrying objects close to his or her center of gravity and draw attention to the feel of balance and control as well as less stress on the neck and back, compared to the feel when carrying objects in more stressful positions. Point out that, when lifting, the closer the object is held to the center of gravity, the less stress is placed on the supporting structures.

• Have the patient practice shifting the load from side-to-side and turning. Have the patient practice turning with hip rotation and minimal trunk rotation. The action should be directed by the legs while the spine is kept stable.

• Replicate the mechanics of the patient's job setting and practice safe mechanics.

• Teach the "golfer's lift" for picking up light objects, such as keys, pencils, and small toys. This is done by flexing the trunk forward over one hip while the other hip extends. It allows the patient to maintain a neutral spine and places the majority of the work on the LEs.

Environmental Adaptations

Ergonomic assessment and modification of the home and working environments are necessary to correct stresses as well as prevent future recurrence of symptoms.

Home, Work, and Driving Considerations

• Chairs and car seats should have lumbar support to maintain slight lordosis. Use a towel roll or lumbar pillow if necessary.

• Chair height should allow knees to flex to take tension off the hamstring muscles, support the thighs, and allow the feet to rest comfortably on the floor.

• Arm rests should be used if prolonged sitting is required in order to take the stress off shoulders and the cervical spine.

• Desk or table height should be adequate to keep the person from having to lean over the work.

• Work and driving habits should allow frequent changing of posture. If normally sedentary, the patient should get up and walk every hour.

Sleeping Environment

• The mattress needs to provide firm support to prevent any extreme stresses. If it is too soft, the patient sags and stresses ligaments; if it is too firm, some patients cannot relax.

• Pillows should be of a comfortable height and density to promote relaxation but should not place joints in an extreme position. Foam rubber pillows tend to cause increased tension in muscles because of the constant resistance they provide.

• Whether the person should sleep prone, side-lying, or supine is something that must be analyzed for each individual patient. Ideally, a comfortable posture is one that is in the mid-range and that does not place stress on any supporting structure. Pain that is experienced when waking up in the morning is often related to sleeping posture; if this is the case, listen carefully to the patient's description of postures when sleeping and see if it relates to the pain. Then, attempt to modify the sleep position accordingly. Remind the patient that it takes several weeks to change habits.

Intermediate to Advanced Exercise Techniques for Functional Training

As the patient learns spinal control while doing the exercises, repetitions are increased to develop muscular endurance, and resistance is added to develop strength. If coordination, agility, and balance are required, they are emphasized. By this stage, it is recognized that the individual already knows the basic spinal stabilization techniques and is habitually assuming the neutral spinal position and activating the drawing-in maneuver. Reinforce the importance of this when doing the following exercises. It is also recognized that the patient should be able to control greater spinal ROM without experiencing symptoms. Adapt the exercises to replicate return to work or sport-related activities. Examples follow.

Repetitive Lifting

The ability to do repetitive lifting throughout the workday is necessary for many jobs and may result in symptom recurrence. To prepare for returning to work, progressively increase the repetitions of lifting activities the patient must do to improve muscle endurance. Marras and Granta³⁶ demonstrated that with repetitive lifting (over a 5-hour period) subjects had a significant change in their lifting pattern and in the muscle recruitment patterns, so there was a decrease in spine stabilization (decreased compression) and an increase in anterior/posterior shear in the lumbar spine. To reduce the risk of recurrence of low-back disorders, a patient needs to learn to monitor these changes and be conscious of correcting faulty patterns. Help the patient modify and adapt the stable spine body mechanics that were initiated under basic techniques to replicate the type of lifting he or she will be doing at home or on the job. Include variations in the lifting tasks to prepare for unexpected situations.

Repetitive Reaching

Repetitive reaching requires that the patient learn to assume a comfortable stride and then practice shifting his or her weight forward and backward on the lower extremities rather than bending forward and backward with the spine. Preparatory exercises should include partial lunging forward, sideways, and backward. During practice, have the patient use a weight comparable to that in the real-life situation and go through the action on a repetitive basis, concentrating on spinal control and resting only when control is no longer possible.

Repetitive Pushing and Pulling

Repetitive pushing and pulling require strong upper extremities and a stable spine. Preparatory activities should include pushing and pulling against elastic resistance or pulley resistance set at heights that replicate the work environment. Progress to pushing and pulling a weighted cart or a weighted box across a table. Reinforce the importance of activating the spinal stabilizers.

Rotation or Turning

Turning with a load is a component of most work activity. A person may rotate the spine to reach around to place a load to the side or behind. Rotation may create an unstable situation or may be damaging to the spinal structures. Therefore, it is important to take the rotation out of turning. Have the patient practice a "stable spine turn," which requires motion and control in the hips or taking steps into the direction of the turn rather than twisting and rotating the back.

Transitional Movements

Most functional activities require transitional motions, such as reaching downward to pick up something (spinal flexion), then reaching overhead to place it on a high shelf (spinal extension). In sports activities, the activity may require moving quickly from a forward-bent position to an extended position with arms overhead (such as dribbling a basketball, then shooting). Set up drills that replicate the speed and movements of the desired outcome; have the patient practice moving through the patterns while attempting to maintain control of his or her functional spinal position and range.

Transfer of Training

Ideally, each patient is progressed through rehabilitation to the level of being able to transfer skills learned to closely related but new situations. Provide variable learning opportunities from simple to complex and then help the patient analyze successful adaptations to each new experience. (See Figure 1.8 and accompanying text in Chapter 1 for examples of how to vary tasks from simple to complex.)

Patient Education for Prevention

Education occurs on a continual basis. Before discharge, review the following relationships of posture and pain with the patient.

• When experiencing pain or the recurrence of symptoms, check posture. Avoid any one posture for prolonged periods.

• If sustained postures are necessary, take frequent breaks and perform appropriate ROM exercises at least every half hour. Finish all exercises by assuming a well-balanced posture.

• Avoid hyperextending the neck or being in a forward-head posture or forward-bent position for prolonged periods. Find ways to modify a task so it can be accomplished at eye level or with proper lumbar support.

• If in a tension-producing situation, perform conscious relaxation exercises.

• Use common sense and follow good safety habits.

• Review the home exercise program and explain how to safely progress and vary the exercises to maintain interest.

  • Teach flexibility, muscle endurance, and strengthening exercises appropriate for the patient to maintain ROM, muscle endurance, and strength.

  • Address any misconceptions the patient may have about exercise and management of the spine.

  • Teach the patient to safely progress the aerobic exercise program. Reinforce the importance of maintaining cardiopulmonary endurance and its effect on managing symptoms.

Critical Thinking and Discussion

1. Observe a homemaker or worker doing an activity that requires pushing, pulling, reaching, lifting, or some other repetitive pattern. Analyze what component motions are part of the total pattern and decide if strength, range, endurance, balance, or coordination (or a combination) is necessary in the upper extremities, lower extremities, and trunk. Decide what is necessary to make the spine safe while doing this activity and design an exercise program that encompasses all the components.

2. Go to a health club or exercise class and observe how individuals are performing the exercises. Note the activities that cause stress to the spine or pelvis. How would you modify each exercise? Consider safe use of the equipment, safe biomechanics, and appropriate instruction for the audience. Can you tell the purpose of each exercise (strength, stretch, endurance, balance)? Are the directions appropriately given for the level of participants?

3. What is the law in your state as it pertains to physical therapists performing manipulation and HVT? What are some situations in which you would perform a manipulation rather than an HVT technique? What are some situations in which you would perform an HVT technique rather than a manipulation technique?

Laboratory Practice

1. With a laboratory partner practice the kinesthetic training techniques and deep segmental muscle activation techniques for the cervical spine and the lumbar spine until you become proficient at performing them and recognizing when they are done correctly. Then practice teaching them to a family member or friend and see how well they understand what they are to do.

2. Practice the progression of spinal stabilization exercises described in the muscle performance section. Start at the easiest level and progress the leg and arm movements until you feel you are at your maximum resistance for stabilization. After resting, time yourself for 1 minute, beginning at the most difficult level of movement. The idea is to keep the spine stable during the entire minute. If you begin to feel you are losing control, decrease the amount of extremity resistance (e.g., going from moving both lower extremities in a reciprocal pattern to moving just one extremity while the other is on the floor). This can also be done for 3 minutes. Were you able to meet the challenge yet keep the spine stable? Did you feel your stabilizing muscles "working"?

3. Practice doing wall slides, partial squats, and partial lunges with a stable spine. When you can do the squat comfortably with a stable spine, practice lifting a box from the floor to table height, then from the floor to shoulder height, then place it on a shelf at each height. Feel what is happening to your spine. Then repeat the maneuvers with a stable spine, and see if you can control the spinal position with the drawing-in maneuver. When you can do the lunge comfortably, practice lifting small objects from the floor with a lunging technique and stable spine. Finally, practice lifting objects from the floor and turning (using legs and hips to change direction, not spinal rotation) to place the objects on a table or shelf. Feel what is happening to the spine and repeat the activities with a stable spinal posture.

4. Review the indications and contraindications for spinal manipulation. Practice the cervical manipulations with your laboratory partner in both the supine and prone positions. In which position do you have better control (patient supine or prone)?

5. Several HVT techniques were discussed in this chapter. What are the contraindications for HVT in the spine? Practice three HVTs to improve thoracic flexion. How would you change the technique if your goal was to improve rotation to the left?

Case Studies

Review the cases described in Chapters 14 and 15 and modify your answers based on the information presented in this chapter.