It is also important to make note of your function, as this may be your first indication of improvement.

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1 Back Pain 1 Management of Back Pain The resolution of pain involves gradually increasing the number of repetitions or resistance of the exercises performed. However, it is important to stay within a range that allows the body to adapt to the new stresses and not increase your present level of pain. Please use the following guideline to help with that. Pain is generally rated on a scale of 0 (no pain/normal) to 10 (worst pain). At no point should exercise create more than a pain level of 1-4 or cause a steady rise in pain. Any increase in pain should be temporary and return to baseline with rest or modalities mentioned below. You should notice an overall decrease in your pain after a few sessions. Should pain increase: 1. Stay at the same number of repetitions and resistance until your soreness decreases 2. Decrease the number of repetitions, staying at the same intensity, progressing more slowly the number of repetitions 3. Decrease both intensity and repetitions, progressing more slowly the number of repetitions It is also important to make note of your function, as this may be your first indication of improvement. Guidelines for Using Cold or Heat Cold: Use bagged frozen vegetables (peas and corn conform best) or bag of ice about one inch thick with a small amount of water in the bottom. Get as much air out of the bag as possible. In the winter you can use snow. Apply for 20 minutes, leaving at least one hour between applications. You can secure the ice with a compression wrap if desired. Ice massage- make a small block of ice in a paper cup or mold and rub the affected area 5-10 minutes until the skin turns red. This technique can be used once an hour. Heat: Place several layers of damp cloth between the skin and the heat source. It is left in place for no more than 30 minutes with two hours between applications. Do not secure heat in place with a compression wrap or weight. The following exercises provide a graduated strengthening program to help you manage your back pain. A mirror should be used in the initial stages to provide visual feedback that you are performing the exercise with correct technique. Improving Torso and Head Posture The single most important thing you can do to help strengthen and re-activate the back muscles is restore as close to a normal torso posture and head position in sitting and standing as possible. This position is called spinal neutral. Sometimes this is not always possible, but the closer you can get too normal, the better your chances of managing your pain. In most cases, back pain causes a posture similar to the one seen here. The back is rounded or shifted to one side and the head is looking down, with the ear in front of the shoulder.

2 Back Pain 2 As seen here, the first step in correcting this posture is to sit up as straight as possible, level the chin and attempt to pull the ear back in line with the shoulder. Once the torso is elevated as far as possible, you want to relearn how to engage the torso muscles by feeling for their contraction ( abdominal hollowing ). This is similar to sucking in your gut. Place one hand in the small of the back, the other over the belly button (Pictures 1-4). You then want to hollow your belly as shown in Pictures 2 and 4. When hollowing: 1. Use the hand in the small of the back to make sure you do not feel your back start to round. 2. The hand over the belly must move backwards towards your insides. Your technique is incorrect if your hand does not move or you feel your muscles tighten but your hand does not move. 3. The natural reaction when first attempting this technique is to hold your breath. Holding your breath is not proper technique. As you practice this exercise, you may notice an increase in your back and possibly neck soreness as the muscles strengthen. This should pass quickly as you continue exercising Picture 1 Picture 2 Picture 3 Picture 4

3 Back Pain 3 The last technique point is to make sure the small muscles involved with stabilizing each vertebra are working. This involves putting the fingers in the area as shown or using a small rolled towel or round object about 1 in diameter to provide sensory feedback (Picture 5). This is a difficult muscle to find and learn how to contract. It is important to do so as these muscles balance the forces created by abdominal hollowing. Picture 5 Stretching As you work on your posture, it is important to restore stretch tolerance to the muscles and nerves. The following exercises will help with that. Quad Active Hamstring- Sitting on a firm chair (not a couch or bed) assume spinal neutral (Picture 6). While holding that posture, begin straightening the knee while letting the foot relax. Do not slouch or lean backward as you straighten the knee. Straighten the knee until you feel a stretching sensation in the hamstring muscle or behind the knee (Picture 7). Picture 6 Picture 7 Once you are in a position of comfortable stretch (1-2 range on the pain scale), pull the foot up as shown in picture 8. Picture 8 Perform 10 repetitions of this exercise 2-3 times a day. Hold each rep 10 seconds, rest 5 seconds between stretches. If you cannot perform the exercise as described, use a footstool or box to support the lower leg, then simply pull the foot back to activate the stretch (Picture 9).

4 Back Pain 4 Picture 9 If you are unable to perform quad active stretch, use the technique shown in Pictures 5-9. Place the leg to be stretched on a bench/table and drape the other leg over the side. Place a strap that will not stretch around the middle of the foot. Using the strap as an anchor, attempt to put your torso in neutral (Picture 10). Do not elevate the leg! You want to feel a moderate pulling sensation (1-2 on the pain scale) in the back of the leg. Perform 3-30s stretches 2-3 times a day. Rest 5 seconds between stretches. Picture 10 Two Position Calf- Place the balls of all 5 toes on a block that is 2-3 inches high. The tendency is for the knee to roll in as shown in picture 13. Equalize pressure across the balls of the toes by moving the kneecap to a forward facing position (Picture 14). Place the foot not being stretched in line with the foot being stretched. For the Straight Knee Stretch (Picture 11), close the angle between the lower leg and foot by leaning the whole body forward. Keeps your hips facing forward. Do not bend from the waist. Do not push the knee forward (squat). The only difference for the Bent Knee Stretch (Picture 12) is to push the knee forward approximately 2 inches. Once the knee is bent, you will feel the stretch drop from the upper calf to the lower calf. Maintain that bent knee angle and again close the distance between the lower leg and foot. Perform 3-30 second stretch in the straight and bent knee position, 2-3 times a day. Rest 5 seconds between stretches. Picture 11 Picture 12 Picture 13 Picture 14

5 Back Pain 5 Strengthening Exercises Bridge- The next exercise is a 5-step strengthening progression. Start with the base position where the hips become the hinge and shoulders to the hips stay rigid. Stage 1- Pick the hips off the floor. Your hips want to be the first thing off the ground and the first thing to touch it. Stage 2- Raise your hips high enough to form a straight line from the shoulder to the knees. Stage 3- Assume the fully elevated position then alternate picking up the right and left foot in a marching pattern. Stage 4- Assume the fully elevated position then alternate straightening the right and left leg. Stage 5- Place both feet on a ball, elevate the hips as in stage one then roll the ball to you by flexing the knees and hips. Do not let your hips touch the ground. Start with one set of 10 reps. Hold each rep 5 seconds. Build up to 4 sets of 10 reps before moving on to the next level of difficulty. Base Position Stage 1 Stage 2 Stage 3 Stage 4 Stage 5B Stage 5A

6 Back Pain 6 Heel Raise: Like the calf stretch, this exercise is performed in straight and bent knee positions. You should initially use a mirror to help monitor proper knee position as shown in Picture 14 (knee over foot and in a line between foot and hip). Technique One (Isometric): As shown in picture 15, place an object or platform about 2 inches in height on the floor. Keep your knees straight and place both hands on a wall or chair(s) to assist with balance. Either: 1. Step back so only the balls of the feet are on the platform and hold the sole of your foot parallel with the floor or 2. Place the balls of all 5 toes on the edge of the platform/block (your heels will be on the ground) and elevate your heels until the sole of your foot is parallel with the floor. Technique Two (Positive): The next step in the progression is to start with the heel on the floor, then elevate it to a position shown in picture 16 (heel raised as high as possible) then return the heel to the floor. Technique Three (Eccentric): The last technique is specific to those with Achilles tendonitis. Start by going up on two feet as shown in picture 16. Lift one foot off the block then lower to a four count on the other leg. Please note that this exercise is considerably harder when done with the knee slightly bent. TWO hands should be used to help steady the body until the exercise becomes comfortable. For each of these techniques, start with 10 reps; add 1-2 reps per day, your goal being reps in straight and bent knee position. Picture 15 Isometric Picture 16 Positive/Start position for Eccentric If you are able, increase the difficulty by using one hand with two feet, then two hands with one foot and finally opposite hand with opposite foot. Picture 17 In addition to strengthening the calf muscles, the muscles on the front of the leg need strengthening. For this exercise, place the heels on a board 1-2 in height. Pick the toes up from the floor, holding the sole of the foot level with the floor (Picture 17). Start with 30 seconds; gradually build up to 2 minutes. Dead Bug- The next exercise focuses on the abdominal muscles and their connection to the quad muscles. Lying down on a firm surface, assume spinal neutral. The progression starts with a four point supported posture (picture 18). Step 1- Alternate raising the right and left leg. Step 2- Raise both feet off the floor (unsupported posture). Step 3- Single arm movements. Step 4- Double arm movements. Step 5- Single leg movements. Step 6- Opposite arm and leg movements (crawling). You must be able

7 Back Pain 7 to hold each position or perform each movement for two continuous minutes before progressing to the next level. Picture 18 Step 1 Step 2 Step 4 Step 3 Step 5 Step 6