Better Back Program. Training Manual

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Julianna Floyd
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Better Back Program Training Manual Clients Suitable for the Better Back Program (BBP) - Back pain patients in need of exercise retraining to improve mobility, CORE strength and fitness.

1 Better Back Program Training Manual Clients Suitable for the Better Back Program (BBP) - Back pain patients in need of exercise retraining to improve mobility, CORE strength and fitness. - People with back pain that effects their quality of life. - Patients who are de-conditioned and need to increase independent activity and fitness levels. - Athletic people with back pain that is affecting their sport and training performance. - Women post pregnancy needing to regain stability and strength. - Workers compensation back pain patients who have reached a plateau with hands on therapy and management. - Back pain patients needing to lose weight and improve fitness. - People who have had surgery for lumbar spine problems and need comprehensive rehabilitation. - Workers in high physical demand employment needing to improve strength and CORE control with exercise. Note: Acute back pain patients may undergo a conventional treatment program of manual therapy, soft tissue massage and acute pain management prior to commencing the Better Back Program. Why Choose the Better Back Program? (The Patients Perspective) - The program has been developed by highly experienced therapists with extensive knowledge in the area of strength, conditioning and functional rehabilitation. - The program uses the latest concepts and research in rehabilitation and core control available today. - The program is the result of more than 20 years of research and professional experience - The program commences with a comprehensive examination and assessment to determine the exact content of the program. - Each program is individualized to each patient no group sessions and involves intensive one-on-one sessions with a trained therapist. - The 3 sessions a week program allows for greater success and more individual attention than less intensive programs (twice per week can be arranged but is not ideal). - All therapists are highly trained in physiotherapy and exercise rehabilitation ensuring exceptional program design and the best possible results. - Private health fund rebates are available for every session (depending on the fund and level of coverage) - There are no lock in contracts with the Better Back Program patients pay on a session by session basis - and are able to suspend their program at any time however for maximum benefits we recommend all patients complete each level in sequence.

2 Why Choose the Better Back Program? (The Therapists Perspective) - This program is probably very similar to the program you are using at the moment in your back rehabilitation programs however the BBP is aiming for a more consistent approach to your sessions. - Increase structure allow you to quickly train junior therapists to use this program and remove some of the problems associated with issues such as frequency of rebooking, and program progression. - Gives a great marketing drive for local doctors and specialists. - Able to market this program to past back pain patients and promote it in our back pain lectures to local gym members and externally. - Increase the number of consults per patient by introducing a structured system of progressions that each patient understands when they start the program. What is involved in the Better Back Program - A comprehensive physical assessment and evaluation to assess suitability for the program - Program design and orientation individually tailored for each patient. - 3 sessions a week of activity based rehabilitation for 4 weeks to allow the program to show results and establish improvements in functional measures and outcomes. - Appointments are made for blocks of 3 sessions at least one week in advance to allow for continuity of therapist and program progression. - One-on-One supervision by a trained physiotherapist in each session followed by independent cardiovascular training to improve general fitness and confidence. - Many patients will require more than 4 weeks of intervention however as much progress is made as possible in this period and then the next stage can be planned and arranged. - Following the initial program recommendations are made and programs are implemented which include regular reviews and independent exercise continuation. Patient Investment to undertake the Better Back Program Initial Assessment and Evaluation (1 Hour) Follow-Up Consultations $ set your price $ set your price Notes: - These fees include gym access for the training component of the program. - Private Health fund rebates are available for all consultations. - Sessions are paid for at the time of the consult there are no lock-in contracts. - Whilst not recommended - patients are able stop or suspend their Better Back program at any time hours notice is required for all cancellations and changes of times or a fee may be charged. - Workers Compensation and CTP patients will be billed directly to the insurer provided claim numbers are current and liability is accepted. - Follow up sessions involve a 30 minute session with the therapist one on one followed by a period of independent CV, strength or mobility exercise in the gym.

3 Program Sessions Outline Initial Assessment (1 hour) 1. New Patient Form completed by the patient before the session 2. Pre-Activity Readiness Questionnaire to be completed and signed by the patient before commencing gym exercise program ( may not be required until Level 2 or 3) 3. Modified Roland Morris (can be done at end of first session if not enough time) 4. Subjective History: - a) use the 3 page Better Back Subjective Assessment form to record findings and guide the initial assessment. b) Therapist MUST watch the Better Back Assessment DVD prior to using this program. 5. Conclusion and Program Content Decided At the conclusion of the 1 hour assessment you may have time to commence the Level One program however if there is no time left tell the patient your plan for the next stages (ie Level One Alignment) and give them a couple of mobility exercises from the Lumbar mobility sheets. If you have a few moments you may also give them an overview of the CV equipment that you will be using at the end of your next session. If time allows set the patient up on the CV apparatus and get them to do approx 10 mins at a low level you will then be able to assess the patients response to this apparatus in the next session and make appropriate modifications (if the patient is to do some CV training in the first session you MUST get them to complete the Pre-Activity Readiness Questionnaire prior to starting the exercise bout). It is important at this stage for you to make the patient aware of your plan and the general details of the Better Back program this is best done by showing the patient the Patient Information Sheet that we have as a laminated version in all treatment rooms for easy access (unless you have already seen the patient before and have gone through the intro sheet with them). This makes the patient more compliant, aware of the 4 levels of the program, understanding of the general time frame we are working under but also appreciative of the time variability we allow to move through the 4 stages. Suitable appointment times are then made for the next 3 sessions in advance ideally on nonconsecutive days. It is wise to make a new appointment at the end of each session that way the patient always has their 3 sessions in advance pre-booked so they do not miss their preferred time slots. If the patient was a direct doctor s referral then an initial report is to be sent within 7 days of this initial consult in keeping with our 7 day letter guarantee.

4 Program Design and Implications The results of the objective and subjective examination will allow the therapist to place the patient on the correct program. Typical training sessions will last mins with the therapist followed by mins of independent CV training. There will be many patients that will not complete the full program in 4 weeks however all efforts should be made to take them as far as possible in the time available. The goal is to show improvements in the first 4 weeks and then encourage the patient to continue with the program until the full course is completed. At the end of each 4 week block a number of tests are repeated to show the patient improvement the actual test used are at the discretion of the treating therapist and are the ones which would have shown the most improvement and/or the test that where poorly performed in the initial assessment. The Better Back Program will utilize the following classifications and program levels: Level One Alignment and CV Fitness This is the starting point for all Better Back patients as the ability to achieve correct alignment allows for more advanced exercises and training programs to follow. The key issues in this stage will depend on the findings from the assessments however here are some suggestions: - Aim to develop and train the concept of a neutral spine to allow good core control to commence (ball mobility exercises may be a good place to teach the patient the neutral spine concept as well as supine flexion and extension motions of the L/S) - All patients MUST spend at least one session on Level One to ensure they have the concept of neutral this is especially important for hypermobile patients. - Use exercises and stretches from Lumbar Spine Stretches 1 and 2 sheets - Use exercises from Thoracic Spine to improve ROM in mid back mobility - Use stretches from Shoulder and Chest to improve upper body mobility. - Use stretches from Hip and Groin to lower upper body mobility. - Use stretches from Thigh and Calf for lower body ROM improvement as this will improve the potential for better core control and alignment. - If the patient was hypermobile on your testing then the use of stretching protocols will not be a major component of your program this patient will move quickly onto Level Two as their issue is one of control and stability not of alignment and mobility, however the neutral spine concept needs to be re-enforced prior to moving to Level 2. - The patient is given the applicable stretching sheets for home use however home stretching is considered a bonus and supervised stretching in the treatment sessions is a major component of the program to ensure compliance and correct techniques are used do not assume that the patient does anything at home and do not make a big issue of it if they do not remember this is a bonus. - You may include some basic swiss ball mobility exercises in this stage as well however do not choose exercises that also demand good CORE control as this has not been established just yet. - The patient may spend between 1 and 6 sessions in Level One depending on their progress obviously a very rigid patient with poor alignment may take longer to progress however there is no point moving this patient on too fast as they will not get adequate CORE control without first improving their alignment this needs to be mentioned and re-enforced to the patient so they do not get frustrated and disheartened by their apparent slow progress you may need to add some more intense CV work to help this patient feel more gains are being made. - The therapist may also include some manual therapy (mobilization / PNF / assisted stretching) in this stage to encourage increased ROM to the rigid segments. Before Moving to Level Two it is assumed that the patient can perform the following: - Have adequate lumbar extension on a McKenzie extension test to be able to rest on the elbows for 30 secs. - Have a thoracic extension test of at least 170 degrees of flexion - Have a SLR of at least 60 degrees range of motion.

5 Level Two Inner Unit and CV Fitness This level is where the concept of CORE control is introduced by the time the patient gets to Level 2 they will have gained adequate ROM, have a good understanding of alignment and have commenced some form of CV fitness training. Some basic Level Two Guidelines include: - Use exercises from Core Stability 1 and 2 sheet. - If the patient has a history of SIJ dysfunction include some exercises from SIJ Exercises - Commence some general weight training exercise if time allows however limit your selection to supported exercises such as seated chest press, supported row, leg press, pulldowns etc until stability improves - CV program should continue as for Level One. - The patient may spend between 1 and 6 sessions at this level depending on their progress and history a surgical patient with long pain history will have many inhibitory problems to overcome before their inner core is working well. Before Moving to Level Three it is assumed that the patient can perform the following: a. TVA Isolation (Prone) Grade 4 (can turn on correctly, able to lift one leg from the bed without excessive contraction) b. Isometric Core Stability (Supine) Grade 4 (able to turn on and lift one leg with knee flexed) c. Active SLR pelvis stays still. Level Three Outer Unit and CV Fitness This level is a progression from the alignment and inner unit stability and now begins to incorporate some of the larger muscles that provide stability to the spine these are more commonly referred to as the sling systems. The sling systems are classified below and are the basis for Level 3 and 4 exercise choices a selection of possible exercises for each of these slings is included it is suggested that at least one exercise from each category is included in all Level 3 programs a) Posterior Oblique Sling (controlling cross stability of the back) - latissimus dorsi, thoracolumbar fascia, gluteus maximus (travelling lunges with medicine ball, woodchoppers, standing cable rows, one arm standing rows with lunge, standing cable rows with squat, bent rows, lunges, step ups, lunge with shoulder press, Ball Bridges, Russian Twist, one leg cable Romanian Deadlift, alternate arm and leg lifts,) b) Posterior Longitudinal Sling (controlling the extensor chain) - erector spinae, sacrotuberous ligament, biceps femoris (deadlifts, step ups, Romanian Deadlifts, squats, overhead squats, travelling lunges, cable step-ups, back extensions, prone supermans, Ball back extensions, Ball Bridging, Cleans, Cable Upright Row from Deadlift with low pulley, upright rows, bicep curls, shoulder presses ) c) Anterior Oblique Sling (controlling diagonal stability across the front of the body) - external oblique, symphysis pubis, adductor longus (standing woodchoppers, cable diagonals, side lunges, cable crossovers, standing cable chest press, standing cable incline press, standing cable shoulder press, standing cable push pull, cable lateral raise with PNF, push-ups, ball push-ups, Bosu Pushups, prone bridging, ball wrestling, ball rollaways, Russian Twist) d) Lateral Sling (controlling lateral support for one leg stability and motion ) - gluteus medius, minimus, tensor fascia lata, adductor on same leg

6 ( lateral lunge, side bridging, side wall squat, standing hip abd/add, lunge, step up, one leg squat, cable side bends, single leg shoulder press) The exercises used in this Level attempt to challenge the patient to increase their stability but not at the expense of good inner unit control when in doubt choose an easier exercise for your patient and always stop the exercise if form and control is lost. Some basic Level Three Guidelines include: - Use exercises from Core Stability 2, 3 and 4 sheets. - If the patient has a history of SIJ dysfunction include some exercises from SIJ Exercises - Use at least one exercise from each of the above sling systems lists. - Use some exercises from the Hip and Groin Exercise sheet excellent for lateral slings and stability. - CV program can expand to more demanding modalities if available and control and alignment is maintained - The patient may spend between 1 and 6 sessions at this level. - Before Moving to Level Four it is assumed that the patient can perform the following: a) Prone bridge 45 secs min b) Prone Leg Lift 30 secs min c) Side Bridge (non irritable patients only) 30 secs min d) Beiring Sorensen (non irritable patients only) 2 min minimum e) Trendelenberg (One Leg Squat/Jump) - stable f) Lunge - stable Level Four Athletic and Maintenance The final level in the Better Back program is the Level 4 Athletic and Maintenance stage. By the time the patient reaches this level they will have satisfied the requirements of good alignment, have gained sound control of the inner unit and have progressed through a series of outer unit exercises as well as established a solid base of CV fitness. The aim of this stage is to provide further challenges to the patient, provide variety to the program and allow the patient to develop the confidence to undertake any work or home activity they desire this may also be the time to return to a chosen sport or exercise that has caused them problems in the past. Some guidelines for Level Four are: - Choose exercises from Core Stability 3 and 4. - If the patient has a history of SIJ dysfunction include some exercises from SIJ Exercises - Use at least two exercises from each of the above sling systems lists. - Help the patient to understand when CORE control is lost and the signs of poor control ie labored breathing, accessory muscle activation, inability to maintain control, poor alignment, general instability then teach the patient to go back to a suitable Inner Unit exercise to re-set and start again. - Make the patient aware of the risk factors for weakened core ie colds and flu, respiratory problems, fatigue. - Incorporate more sports specific exercises if a return to sport is planned likewise for return to more advanced work duties. - CV options should now be more open and can include some running, stepper, and rower. CV Training Tips for all levels - Aim to get your patient to do mins of CV work at the end of each session in Level One and increase to a consistent 30 mins per session by the end of the first 4 weeks. - Use a PRE scale of approx 6/10 and modify if required. - The importance of CV fitness in back rehabilitation cannot be over emphasized some benefits of CV fitness to back pain patients include:

7 a) increased oxygen delivery to the working muscles and recovering injured muscles. b) changes to the pain pathways and changing the input to the pain sensitive structures. c) increased self esteem, achievement and confidence improving compliance and program success. d) reduced stress on the diaghram during activity leading to improved core control during exercise.

8 - The choice of CV apparatus will depend on their segmental mobility, personal preference and history of exercise however ensure that your choice of modality reflects the goal of their program stage eg: a) Do not give a patient with an increased thoracic kyphosis the rower as their CV modality as this will encourage more thoracic flexion b) Use the recumbent bike for hypermobility patients with poor stability. c) The upright bike can be used however ensure that the pelvis is able to me kept level and core control is maintained. d) Running should be limited to those patients with good stability and good alignment. e) Treadmill walking and running should be kept on the flat as much as possible. f) The stepper should be left for the more advanced stages of the program as stability improves. g) Swimming is an excellent mobility tool for level one patient s if you have a pool available however be aware that you need to be a good swimmer to get good CV results from swimming your patient may still require other CV modalities to supplement the swimming training. The Final Consult It is highly unlikely that a patient will be able to progress through the Better Back program in 4 weeks however this is what we are ideally aiming for it may be more likely that each level will take between 2 and 4 weeks. The basic outline of the program is to provide therapists and patients with the framework to base their progression around and allow some consistency across clinics as well a differentiate you business from other back pain rehabilitation providers. In the final consult recommendations are made for maintenance and final program changes are made a letter is then sent off to the referring doctor outline the end results. The patient must also be encouraged to have regular massage and review sessions in the future a phone call should also be made in 1 week to check on the patient s progress following discharge. There is also the suggestion that the patient take up a regular gym membership to continue their success this is also a good cross promotion opportunity with the gym sales team.

EXERCISE PHOTOS, TIPS AND INSTRUCTIONS

Page 1 of 21 EXERCISE PHOTOS, TIPS AND INSTRUCTIONS Page 2. Squat Page 12. Crab Walks Page 3. Single Leg Squat Page 13. Bench Press Page 4. Split Squat Page 14. Bench Pull Page 5. Deadlift Page 15. Shoulder