DPT 772 Spine Notebook Matt Kubalski, SPT

Transcription

1 DPT 772 Spine Notebook Matt Kubalski, SPT

2 Table of Contents: IMPAIRMENTS/CLASSIFICATIONS PAGES Neck Pain with Mobility Deficit: Cervicalgia, Pain in thoracic spine - JOSPT 3-6 Neck Pain with Headache: Headache, cervicocranial syndrome JOSPT 7-10 Neck Pain with Movement Coordination Impairments: sprain and strain of C-spine - JOSPT Neck Pain with Radiating Pain: Spondylosis with radiculopathy, cervical disc disorder with radiculopathy - JOSPT Acute/subacute Low Back Pain with Mobility Deficits - JOSPT Acute/subacute/chronic Low Back Pain with Movement Coordination Impairments - JOSPT Acute Low Back Pain with Related (referred) Lower Extremity Pain - JOSPT Acute/subacute/chronic Low Back Pain with Radiating Pain - JOSPT Acute/subacute Low Back Pain with Related Cognitive or Affective Tendencies - JOSPT Chronic Low Back Pain with Related Generalized Pain JOSPT Derangement Syndrome MDT Dysfunction Syndrome MDT Postural Syndrome MDT Various Illustrations of stabilization, progressive loading and MDT exercises Kisner and Wise 58-65

3 Neck Pain with Mobility Deficit: Cervicalgia, Pain in thoracic spine Symptoms: Unilateral neck pain Neck motion limitations Onset of symptoms is often linked to a recent unguarded/awkward movement or position Associated (referred) UE pain may be present Impairments: Limited cervical ROM Neck pain reproduced at end ranges of AROM and PROM Restricted cervical and thoracic segmental mobility Neck and neck-related UE pain reproduced with provocation of the involved cervical or upper thoracic segments Key Concordant Signs: Familiar symptoms (unilateral neck pain, referred UE pain) reproduced with AROM or PROM and provocation of the involved segments Physical Exams to Rule In: Cervical AROM Cervical and thoracic segmental mobility Management for Each Stage of Healing: Cervical and thoracic mobilization/manipulation Stretching exercises Coordination, strengthening, and endurance exercises **See the table below for more details** Phases of Rehabilitation Intervention Kinesthetic awareness Proprioce ption training of safe movemen t and postures Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Cervical retraction: passive active assist in comfortable positions Awareness of what makes symptoms better vs. worse Learn neutral spine (or bias) Basic Training/Controlled motion Phase Moderate to minimum protection Active cervical control in various positions supine, prone, quadruped, sitting, standing Have patient practice moving into and out of cervical retraction to develop control Dynamic maintenance of pain-free position with activities Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine (cervical retraction) in all functional activities Return to normal ADLs, activities, work, function

4 Mobility/flexibilit y Move, stretch, manipulat e restricting tissues Muscle performance Stabilizati on training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Cervical and thoracic PA mobilizations grades 1 and 2 for pain control Gentle stretching of tight musculature/tissue in pain-free range Activation of deep neck flexor musculature using The Stabilizer biofeedback device: patient supine hold 10 seconds x 10 repetitions for cervical flexors progressing supine sitting stan ding with wall support standing with no support (shoulder flexion to 90, shoulder abduction to 90, and shoulder external rotation with arms at sides) Activation of cervical and thoracic extensors: patient prone, lift forehead off exercise mat and hold for 10 seconds x 10 repetitions for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off Cervical and thoracic mobilizations grade 3 to increase segmental mobility Gentle stretching of tight musculature/tissue and spinal movement into painful range Teach self-stretching exercises for cervical and thoracic spine (upper trapezius, scalenes, thoracic spine, suboccipital muscles) Muscle energy techniques to increase rotation for cervical flexors progressing supine sitting stan ding with wall support standing with no support (shoulder flexion to end range, shoulder ABD combined with ER to end range, diagonal PNF patterns) for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (elevate shoulder in full flexion, arms ABD to 90 and laterally rotated, elbows extended: horizontally ABD shoulders and ABB scapulae, UE diagonal PNF patterns) Cervical and thoracic mobilizations and manipulation grades IV and thrust to increase segmental mobility Continue to stretch tight tissue and perform exercises/activities in painful/end range positions for cervical flexors progressing supine sitting stan ding with wall support standing with no support (reaching forward, outward, upward in functional patterns, pushing/puling and lifting activities) for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (reaching forward, outward, upward in functional patterns, pushing/pulling and lifting activities) Intermediate and advanced training transitional stabilization for the cervical and upper

5 table quadruped s tanding with wall support standing no support (arms at side: laterally rotate shoulders and adduct scapulae) Isometric exercises for cervical flexion, extension, rotation and sidebending. Dynamic cervical flexion thoracic regions (exercise ball roll out) Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, communit y, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end range positions such as hyper extension, use

6 common sense and follow good safety habits, review the HEP)

7 Neck Pain with Headache: Headache, cervicocranial syndrome Symptoms: Non-continuous, unilateral neck pain and associated (referred) headache Headache is precipitated or aggravated by neck movements or sustained positions Impairments: Headache reproduced with provocation of the involved upper cervical segments Limited cervical range of motion Restricted upper cervical segmental mobility Strength and endurance deficits of the deep neck flexor muscles Key Concordant Signs: Familiar symptoms (neck pain, headache) reproduced with provocation of the involved segments Physical Exams to Rule In: Cervical AROM Cervical segmental mobility (PA mobs) Cranial cervical flexion test Management for Each Stage of Healing: Cervical mobilization/manipulation Stretching exercises Coordination, strengthening, and endurance exercises **See the table below for more details** Phases of Rehabilitation Intervention Kinesthetic awareness Proprioce ption training of safe movemen t and postures Mobility/flexibilit y Move, stretch, manipulat e restricting tissues Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Cervical retraction: passive active assist active in comfortable positions Awareness of what makes symptoms better vs. worse Learn neutral spine (or bias) Cervical PA mobilizations grades 1 and 2 for pain control Gentle suboccipital release/traction Gentle stretching of tight musculature/tissue in pain-free range Basic Training/Controlled motion Phase Moderate to minimum protection Active cervical control in various positions supine, prone, quadruped, sitting, standing Have patient practice moving into and out of cervical retraction to develop control Dynamic maintenance of pain-free position with activities Cervical grade 3 to increase segmental mobility Suboccipital release/traction Gentle stretching of tight musculature/tissue and spinal movement into painful range Teach self-stretching exercises for cervical and thoracic spine (upper trapezius, Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine (cervical retraction) in all functional activities Return to normal ADLs, activities, work, function Cervical mobilizations and manipulation grades IV and thrust to increase segmental mobility Continue to stretch tight tissue and perform exercises/activities in painful/end range positions

8 scalenes, thoracic spine, suboccipital muscles) Muscle performance Stabilizati on training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of deep neck flexor musculature using The Stabilizer biofeedback device: patient supine hold 10 seconds x 10 repetitions for cervical flexors progressing supine sitting stan ding with wall support standing with no support (shoulder flexion to 90, shoulder abduction to 90, and shoulder external rotation with arms at sides) Activation of cervical and thoracic extensors: patient prone, lift forehead off exercise mat and hold for 10 seconds x 10 repetitions for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (arms at side: laterally rotate shoulders and adduct scapulae) for cervical flexors progressing supine sitting stan ding with wall support standing with no support (shoulder flexion to end range, shoulder ABD combined with ER to end range, diagonal PNF patterns) for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (elevate shoulder in full flexion, arms ABD to 90 and laterally rotated, elbows extended: horizontally ABD shoulders and ABB scapulae, UE diagonal PNF patterns) Dynamic cervical flexion for cervical flexors progressing supine sitting stan ding with wall support standing with no support (reaching forward, outward, upward in functional patterns, pushing/puling and lifting activities) for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (reaching forward, outward, upward in functional patterns, pushing/pulling and lifting activities) Intermediate and advanced training transitional stabilization for the cervical and upper thoracic regions (exercise ball roll out)

9 Isometric exercises for cervical flexion, extension, rotation and sidebending. Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, communit y, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end range positions such as hyper extension, use

10 common sense and follow good safety habits, review the HEP)

11 Neck Pain with Movement Coordination Impairments: sprain and strain of C-spine Symptoms: Neck pain and associated (referred) UE pain Symptoms are often linked to a precipitating trauma/whiplash and may be present for an extended period of time Impairments: Strength, endurance, and coordination deficits of the deep neck flexor muscles Neck pain with mid-range motion that worsens with end range movements or positions Neck and neck-related UE pain reproduced with provocation of the involved cervical segment(s) Cervical instability may be present (note that muscle spasm adjacent to the involved cervical segment(s) may prohibit accurate testing) Key Concordant Signs: Familiar symptoms (neck pain, referred UE pain) reproduced with mid-range to end-range motion and provocation of the involved cervical segments Physical Exams to Rule In: Cranial cervical flexion test Deep neck flexor endurance Management for Each Stage of Healing: Coordination, strengthening, and endurance exercises Patient education and counseling Stretching exercises **See the table below for more details** Phases of Rehabilitation Intervention Kinesthetic awareness Proprioce ption training of safe movemen t and postures Mobility/flexibilit y Move, stretch, manipulat e restricting tissues Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Cervical retraction: passive active assist active in comfortable positions Awareness of what makes symptoms better vs. worse Learn neutral spine (or bias) Gentle suboccipital release/traction Gentle stretching of tight musculature/tissue in pain-free range Basic Training/Controlled motion Phase Moderate to minimum protection Active cervical control in various positions supine, prone, quadruped, sitting, standing Have patient practice moving into and out of cervical retraction to develop control Dynamic maintenance of pain-free position with activities Suboccipital release/traction Gentle stretching of tight musculature/tissue and spinal movement into painful range Teach self-stretching exercises for cervical and thoracic spine (upper trapezius, scalenes, thoracic Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine (cervical retraction) in all functional activities Return to normal ADLs, activities, work, function Continue to stretch tight tissue and perform exercises/activities in painful/end range positions

12 spine, suboccipital muscles) Muscle performance Stabilizati on training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of deep neck flexor musculature using The Stabilizer biofeedback device: patient supine hold 10 seconds x 10 repetitions for cervical flexors progressing supine sitting stan ding with wall support standing with no support (shoulder flexion to 90, shoulder abduction to 90, and shoulder external rotation with arms at sides) Possibly Extensors - Activation of cervical and thoracic extensors: patient prone, lift forehead off exercise mat and hold for 10 seconds x 10 repetitions Possibly Extensors - Stabilization exercises for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (arms at side: laterally rotate for cervical flexors progressing supine sitting stan ding with wall support standing with no support (shoulder flexion to end range, shoulder ABD combined with ER to end range, diagonal PNF patterns) Possibly Extensors - Stabilization exercises for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (elevate shoulder in full flexion, arms ABD to 90 and laterally rotated, elbows extended: horizontally ABD shoulders and ABB scapulae, UE diagonal PNF patterns) Dynamic cervical flexion for cervical flexors progressing supine sitting stan ding with wall support standing with no support (reaching forward, outward, upward in functional patterns, pushing/puling and lifting activities) Possibly Extensors - Stabilization exercises for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (reaching forward, outward, upward in functional patterns, pushing/pulling and lifting activities) Intermediate and advanced training transitional stabilization for the cervical and upper thoracic regions (exercise ball roll out)

13 shoulders and adduct scapulae) Isometric exercises for cervical flexion, extension, rotation and sidebending. Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, communit y, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end range positions such as hyper extension, use

14 common sense and follow good safety habits, review the HEP)

15 Neck Pain with Radiating Pain: Spondylosis with radiculopathy, cervical disc disorder with radiculopathy Symptoms: Neck pain with associated radiating (narrow band of lancinating) pain in the involved upper extremity Upper extremity paresthesias, numbness, and weakness may be present Impairments: Neck and neck-related radiating pain reproduced with: o 1. Cervical extension, sidebending, and rotation toward the involved side (Spurling s test) o 2. Upper limb tension testing Neck and neck-related radiating pain relieved with cervical distraction May have upper extremity sensory, strength, or reflex deficits associated with the involved nerve(s) Key Concordant Signs: Familiar symptoms (neck pain, upper extremity symptoms) reproduced with cervical extension, sidebending, and/or rotation Physical Exams to Rule In: Upper limb tension test Spurling s test Management for Each Stage of Healing: Distraction test Upper quarter and nerve mobilization procedures Traction Thoracic mobilization/manipulation **See the table below for more details** Phases of Rehabilitation Intervention Kinesthetic awareness Proprioce ption training of safe movemen t and postures Mobility/flexibilit y Move, stretch, manipulat e restricting tissues Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Cervical retraction: passive active assist active in comfortable positions Awareness of what makes symptoms better vs. worse Learn neutral spine (or bias) Thoracic mobilizations grades 1 and 2 Gentle suboccipital/cervical traction Gentle stretching of tight musculature/tissue in pain-free range Basic Training/Controlled motion Phase Moderate to minimum protection Active cervical control in various positions supine, prone, quadruped, sitting, standing Have patient practice moving into and out of cervical retraction to develop control Dynamic maintenance of pain-free position with activities Thoracic mobilizations grade 3 Suboccipital/cervical traction Gentle stretching of tight musculature/tissue and spinal movement into painful range Teach self-stretching exercises for cervical, Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine (cervical retraction) in all functional activities Return to normal ADLs, activities, work, function Thoracic mobilization grade 4 and manipulation Continue to stretch tight tissue and perform exercises/activities in painful/end range positions

16 Gentle nerve mobilization techniques thoracic spine and involved upper extremity (upper trapezius, scalenes, thoracic spine, suboccipital muscles, tight UE musculature) Progressive nerve mobilization techniques Progress nerve mobilization to end ranges Muscle performance Stabilizati on training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of deep neck flexor musculature using The Stabilizer biofeedback device: patient supine hold 10 seconds x 10 repetitions for cervical flexors progressing supine sitting stan ding with wall support standing with no support (shoulder flexion to 90, shoulder abduction to 90, and shoulder external rotation with arms at sides) Activation of cervical and thoracic extensors: patient prone, lift forehead off exercise mat and hold for 10 seconds x 10 repetitions for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (arms at side: laterally rotate shoulders and adduct scapulae) for cervical flexors progressing supine sitting stan ding with wall support standing with no support (shoulder flexion to end range, shoulder ABD combined with ER to end range, diagonal PNF patterns) for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (elevate shoulder in full flexion, arms ABD to 90 and laterally rotated, elbows extended: horizontally ABD shoulders and ABB scapulae, UE diagonal PNF patterns) Dynamic cervical flexion for cervical flexors progressing supine sitting stan ding with wall support standing with no support (reaching forward, outward, upward in functional patterns, pushing/puling and lifting activities) for cervical and thoracic extensors progressing prone forehead on treatment table and lift forehead off table quadruped s tanding with wall support standing no support (reaching forward, outward, upward in functional patterns, pushing/pulling and lifting activities) Intermediate and advanced training transitional stabilization for the cervical and upper thoracic regions (exercise ball roll out)

17 Isometric exercises for cervical flexion, extension, rotation and sidebending. Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, communit y, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end range positions such as hyper extension, use

18 common sense and follow good safety habits, review the HEP)

19 Acute/Subacute Low Back Pain with Mobility Deficits Symptoms: Acute/subacute low back, buttock, or thigh pain Unilateral pain Onset of symptoms is often linked to a recent unguarded/awkward movement or position May report sensation of back stiffness Impairments: Acute: Lumbar ROM limitations Restricted lower thoracic and lumbar segmental mobility Low back and low back-related LE symptoms are reproduced with provocation of the involved lower thoracic, lumbar, or sacroiliac segments Subacute: Symptoms reproduced with end-range spinal motions Symptoms reproduced with provocation of the involved lower thoracic, lumbar, or sacroiliac segments. Presence of 1 or more of the following: o Restricted thoracic ROM and associated segmental mobility o Restricted lumbar ROM and associated segmental mobility o Restricted lumbopelvic or hip ROM and associated accessory mobility Key Concordant Signs: Acute: Acute low back, buttock, or thigh pain (duration of 1 month or less) Subacute: Subacute, unilateral, low back, buttock, or thigh pain Physical Exams to Rule In: AROM for thoracic and lumbar spine and hip, PA mobs for segmental mobility Management for Each Stage of Healing: and symptom provocation, PROM hip motion Acute: Manual therapy procedures (thrust manipulation and other non-thrust mobilization techniques) to diminish pain and improve segmental spinal or lumbopelvic motion Therapeutic exercises to improve or maintain spinal mobility Patient education that encourages the patient to return to or pursue an active lifestyle Subacute: Manual therapy procedures to improve segmental spinal, lumbopelvic, and hip mobility Therapeutic exercises to improve or maintain spinal and hip mobility Focus on preventing recurring low back pain episodes through the use of (1) therapeutic exercises that address coexisting coordination impairments strength deficits, and endurance deficits, and (2) education that encourages the patient to pursue or maintain an active lifestyle **See the table below for more details**

20 Phases of Rehabilitation Intervention Kinesthetic awareness Proprioceptio n training of safe movement and postures Mobility/flexibility Move, stretch, manipulate restricting tissues Muscle performance training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Pelvic tilt: passive active assist active. Teach the patient to move his or her pelvis in an anterior and posterior pelvic tilt in a comfortable range Awareness of what (postures/movements ) makes symptoms better vs. worse Learn neutral spine (or bias) Lumbar and thoracic PA mobilizations grades 1 and 2 for pain control Gentle stretching of tight musculature/tissue in pain-free range in low back and hips Activation of TA and multifidus using The Stabilizer biofeedback device: hold 10 seconds x 10 repetitions TA: patient supine bent leg fallout with TA activation trunk extensors/multifidus: quadruped unilateral arm raise or unilateral leg extension Basic Training/Controlled motion Phase Moderate to minimum protection Active spinal control in various positions supine, prone, quadruped, sitting, standing Dynamic maintenance of pain-free position with activities Lumbar and thoracic mobilizations grade 3 to increase segmental mobility Gentle stretching of tight musculature/tissue and spinal movement into painful range for low back and hips Teach selfstretching exercises exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine in all functional activities Return to normal ADLs, activities, work, function Lumbar and thoracic mobilizations and manipulation grades IV and thrust to increase segmental mobility Continue to stretch tight tissue and perform exercises/activities in painful/end range positions exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement

21 exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Intermediate training: curl-ups, curl-downs, diagonal curl-up, double knee to chest, pelvic lifts, bilateral straight leg raising/lowering, thoracic elevation, leg lifts, superman, quadratus lumborum side plank exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Advanced functional training: curl-ups on unstable surface, trunk flexion sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, trunk extension sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, quadratus lumborum side plank progression Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient

22 Functional Activities Body mechanics Skill in home, community, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end range positions such as hyper extension, use common sense and follow good safety habits, review the HEP)

23 Acute/Subacute/Chronic Low Back Pain with Movement Coordination Impairments Symptoms: Acute: Acute exacerbation of recurring low back pain that is commonly associated with referred LE pain Symptoms often include numerous episodes of low back and/or low backrelated lower extremity pain in recent years Subacute: Subacute, recurring low back pain that is commonly associated with referred LE pain Symptoms often include numerous episodes of low back and/or low back related LE pain in recent years Chronic: Chronic, recurring low back pain and associated (referred) LE pain Impairments: Acute: Low back and/or low back related LE pain at rest or produced with initial to mid range spinal movements Low back and/or low back related LE pain reproduced with provocation of the involved lumbar segment(s) Movement coordination impairments of the lumbopelvic region with low back flexion and extension movements Subacute: Lumbosacral pain with mid range motions that worsen with end range movements or positions Low back and low back related LE pain reproduced with provocation of the involved lumbar segment(s) Lumbar hypermobility with segmental mobility assessment may be present Mobility deficits of the thorax and/or lumbopelvic/hip regions Diminished trunk or pelvic region muscle strength and endurance Movement coordination impairments while performing self-care/home management activities Chronic: Presence of 1 or more of the following: o Low back and/or low back related LE pain that worsens with sustained end range movements or positions o Lumbar hypermobility with segmental motion assessment o Mobility deficits of the thorax and lumbopelvic/hip regions o Diminished trunk or pelvic region muscle strength and endurance o Movement coordination impairments while performing community/work related recreational or occupational activities Key Concordant Signs: Acute: Familiar symptoms (acute exacerbation of recurring low back pain and referred LE pain) reproduced with initial to mid-range spinal movements and provocation of the involved lumbar segment(s). Subacute: Familiar symptoms (subacute exacerbation of recurring low back pain and referred LE pain) reproduced with mid-range motions that worsen with end range movements or positions and provocation of the involved lumbar segment(s). Chronic: Familiar symptoms (chronic recurring low back pain and referred LE pain) reproduced with sustained end range movements or positions.

24 Physical Exams to Rule In: AROM of thoracic and lumbar spine and hip, PA mobs for segmental mobility and symptom provocation, observation for aberrant motion, trunk and pelvic region muscle strength and endurance tests, prone instability test, PROM hip motions Management for Each Stage of Healing: Acute: Neuromuscular re-education to promote dynamic (muscular) stability to maintain the involved lumbosacral structures in less symptomatic, mid-range positions. Consider the use of temporary external devices to provide passive restraint to maintain the involved lumbosacral structures in less symptomatic, mid-range positions Self-care/home management training pertaining to (1) postures and motions that maintain the involved spinal structures in neutral, symptom-alleviating positions, and (2) recommendations to pursue or maintain an active lifestyle Subacute: Neuromuscular re-education to promote dynamic (muscular) stability to maintain the involved lumbosacral structures in less symptomatic, mid-range positions during self-care related functional activities. Manual therapy procedures and therapeutic exercises to address identified thoracic spine, ribs, lumbopelvic, or hip mobility deficits. Therapeutic exercises to address trunk and pelvic-region muscle strength and endurance deficits Self-care/home management training in maintaining the involved structures in mid-range, less symptom-producing positions Initiate community/work reintegration training in pain management strategies while returning to community/work activities. Chronic: Neuromuscular re-education to promote dynamic (muscular) stability to maintain the involved lumbosacral structures in less symptomatic, mid-range positions during household, occupational or recreational activities. The rest is the same as subacute. **See the table below for more details**

25 Phases of Rehabilitation Intervention Kinesthetic awareness Proprioceptio n training of safe movement and postures Mobility/flexibility Move, stretch, manipulate restricting tissues Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Pelvic tilt: passive active assist active. Teach the patient to move his or her pelvis in an anterior and posterior pelvic tilt in a comfortable range Awareness of what (postures/movements ) makes symptoms better vs. worse Learn neutral spine (or bias) Lumbar and thoracic PA mobilizations grades 1 and 2 for pain control Gentle stretching of tight musculature/tissue in pain-free range in low back and hips Basic Training/Controlled motion Phase Moderate to minimum protection Active spinal control in various positions supine, prone, quadruped, sitting, standing Dynamic maintenance of pain-free position with activities Lumbar and thoracic mobilizations grade 3 to increase segmental mobility Gentle stretching of tight musculature/tissue and spinal movement into painful range for low back and hips Teach selfstretching exercises Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine in all functional activities Return to normal ADLs, activities, work, function Lumbar and thoracic mobilizations and manipulation grades IV and thrust to increase segmental mobility Continue to stretch tight tissue and perform exercises/activities in painful/end range positions Muscle performance training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of TA and multifidus using The Stabilizer biofeedback device: hold 10 seconds x 10 repetitions TA: patient supine bent leg fallout with TA activation trunk extensors/multifidus: quadruped unilateral arm raise or unilateral leg extension exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance)

26 bilateral LE movement exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Intermediate training: curl-ups, curl-downs, diagonal curl-up, double knee to chest, pelvic lifts, bilateral straight leg raising/lowering, thoracic elevation, leg lifts, superman, quadratus lumborum side plank bilateral LE movement exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Advanced functional training: curl-ups on unstable surface, trunk flexion sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, trunk extension sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, quadratus lumborum side plank progression Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient

27 Functional Activities Body mechanics Skill in home, community, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end range positions such as hyper extension, use common sense and follow good safety habits, review the HEP)

28 Acute Low Back Pain with Related (referred) Lower Extremity Pain Symptoms: Acute low back pain that is commonly associated with referred buttock, thigh, or leg pain Symptoms are often worsened with flexion activities and sitting Impairments: Low back and LE pain that can be centralized and diminished with specific postures and/or repeated movements Reduced lumbar lordosis Limited lumbar extension mobility Lateral trunk shift may be present Clinical findings consistent with subacute or chronic low back pain with movement coordination impairments classification criteria Key Concordant Signs: Familiar symptoms (acute low back pain, referred buttock, thigh, or leg pain) reproduced with flexion activities and sitting Physical Exams to Rule In: AROM of trunk, repeated motions of trunk and postures looking for centralized/diminished symptoms, observation for lateral trunk shift, PA mobs for lumbar spine for segmental mobility and symptom provocation, trunk muscle power and endurance tests Management for Each Stage of Healing: Therapeutic exercises, manual therapy, or traction procedures that promote centralization and improve lumbar extension mobility Patient education in positions that promote centralization Progress to interventions consistent with the Subacute or Chronic Low Back Pain with Movement Coordination Impairments intervention strategies **See the table below for details** Phases of Rehabilitation Intervention Kinesthetic awareness Propriocepti on training of safe movement and postures Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Pelvic tilt: passive active assist active. Teach the patient to move his or her pelvis in an anterior and posterior pelvic tilt in a comfortable range Awareness of what (postures/movemen ts) makes symptoms better vs. worse Learn neutral spine (or bias) Basic Training/Controlled motion Phase Moderate to minimum protection Active spinal control in various positions supine, prone, quadruped, sitting, standing Dynamic maintenance of pain-free position with activities Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine in all functional activities Return to normal ADLs, activities, work, function

29 Mobility/flexibility Move, stretch, manipulate restricting tissues Lumbar PA mobilizations grades 1 and 2 for pain control Gentle stretching of tight musculature/tissue in pain-free range in low back and hips Gentle hip side glides if lateral shift is present Repeated motions/stretching in the direction that diminishes symptoms in painfree range Lumbar and mobilizations grade 3 to increase segmental mobility Gentle stretching of tight musculature/tissu e and spinal movement into painful range for low back and hips Repeated motions/stretchin g in direction that diminishes symptoms Teach selfstretching exercises Hip side glides if lateral shift present Lumbar mobilizations and manipulation grades IV and thrust to increase segmental mobility Continue to stretch tight tissue and perform exercises/activities/repea ter motions in painful/end range positions Muscle performance training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of TA and multifidus using The Stabilizer biofeedback device: hold 10 seconds x 10 repetitions exercises TA: patient supine bent leg fallout with TA activation exercises trunk extensors/multifidus : quadruped unilateral arm raise or unilateral leg extension exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifid us starting quadruped than progressing to prone. Quadruped progression: flex (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement for trunk extensors/multifidus starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE

30 one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Intermediate training: curl-ups, curl-downs, diagonal curl-up, double knee to chest, pelvic lifts, bilateral straight leg raising/lowering, thoracic elevation, leg lifts, superman, quadratus lumborum side plank lift head, arms and LE off table Advanced functional training: curl-ups on unstable surface, trunk flexion sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, trunk extension sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, quadratus lumborum side plank progression Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient

31 Functional Activities Body mechanics Skill in home, community, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, pushups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end range positions such as hyper extension, use common sense and follow good safety habits, review the HEP)

32 Acute/Subacute/Chronic Low Back Pain with Radiating Pain Symptoms: Acute: Acute low back pain with associated radiating (narrow band of lancinating) pain in the involved LE LE paresthesias, numbness, and weakness may be reported Subacute: Subacute, recurring, mid-back and/or low back pain with associated radiating pain in the involved LE LE paresthesias, numbness, and weakness may be reported Chronic: Chronic, recurring, mid- and/or low back pain with associated radiating pain in the involved lower extremity LE paresthesias, numbness, and weakness may be reported Impairments: Acute: LE radicular symptoms that are present at rest or produced with initial to midrange spinal mobility, lower limb tension tests/straight leg raising, and/or slump tests Signs of nerve root involvement may be present It is common for the symptoms and impairments of body function in patients who have acute low back pain with radiating pain to also be present in patients who have acute low back pain with related (referred) lower extremity pain Subacute: Mid-back, low back, and back-related radiating pain or paresthesia that are reproduced with mid-range and worsen with end range: o Lower limb tension testing/straight leg raising tests, and/or.. o Slump tests o May have LE sensory, strength, or reflex deficits associated with the involved nerve(s) Chronic: Mid-back, low back, or LE pain or paresthesias that are reproduced with sustained end-range lower-limb tension tests and/or slump tests Signs of nerve root involvement may be present Key Concordant Signs: Acute: Familiar symptoms of acute low back pain with associated radiating pain the involved LE, as well as LE paresthesias, numbness, and weakness. Symptoms reproduced with initial to mid-range spinal mobility, lower-limb tension/straight leg raising and or slump tests. Signs of nerve root involvement may be present. Subacute: Familiar symptoms of subacute, recurring mid-back and/or low back pain with associated radiating pain and potential sensory, strength or reflex deficits in the involved LE. Symptoms reproduced with mid-range and worsen with end range lower-limb tension/straight leg raising and/or slump tests. Chronic: Familiar symptoms of chronic, recurring mid-back and/or low back pain with associated radiating pain and potential sensory, strength or reflex deficits in the involved LE. Symptoms reproduced with sustained end range lower-limb tension/straight leg raising and/or slump tests. Physical Exams to Rule In: Trunk AROM with repeated movements, lower limb tension tests, straight leg raise, slump test, myotomes, dermatomes, reflexes Management for Each Acute: Stage of Healing: Patient education in positions that reduce strain or compression to the involved nerve root(s) or nerves Manual or mechanical traction

33 Manual therapy to mobilize the articulations and soft tissues adjacent to the involved nerve root(s) or nerves that exhibit mobility deficits Nerve mobility exercises in the pain-free, non symptom-producing ranges to improve the mobility of central (dural) and peripheral neural elements Subacute: Manual therapy to mobilize the articulations and soft tissues adjacent to the involved nerve root(s) or nerves that exhibit mobility deficits Manual or mechanical traction Nerve mobility and slump exercises in the mid- to end ranges to improve the mobility of central (dural) and peripheral neural elements Chronic Manual therapy and therapeutic exercises to address thoracolumbar and lowerquarter nerve mobility deficits Patient education pain management strategies **See below for more details** Phases of Rehabilitation Intervention Kinesthetic awareness Propriocepti on training of safe movement and postures Mobility/flexibility Move, stretch, manipulate restricting tissues Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Pelvic tilt: passive active assist active. Teach the patient to move his or her pelvis in an anterior and posterior pelvic tilt in a comfortable range Awareness of what (postures/movemen ts) makes symptoms better vs. worse Learn neutral spine (or bias) Lumbar PA mobilizations grades 1 and 2 for pain control Gentle passive stretching of tight musculature/tissue in pain-free range of LE Gentle repeated AROM of trunk in direction that Basic Training/Controlled motion Phase Moderate to minimum protection Active spinal control in various positions supine, prone, quadruped, sitting, standing Dynamic maintenance of pain-free position with activities Lumbar PA mobilizations grade 3 for segmental mobility Active stretching of tight musculature/tissu e and spinal movement into painful range for LE Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine in all functional activities Return to normal ADLs, activities, work, function Lumbar mobilizations and manipulation grades IV and thrust to increase segmental mobility Continue to stretch tight tissue and perform exercises/activities/repea ter motions in painful/end range positions Continue LE nerve mobilization techniques

34 Muscle performance training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power diminishes symptoms Gentle LE nerve mobilization techniques for sciatic and/or femoral nerves Activation of TA and multifidus using The Stabilizer biofeedback device: hold 10 seconds x 10 repetitions exercises TA: patient supine bent leg fallout with TA activation exercises trunk extensors/multifidus : quadruped unilateral arm raise or unilateral leg extension Repeated AROM of trunk in direction that diminishes symptoms Teach selfstretching exercises for LE LE nerve mobilization techniques for sciatic and/or femoral nerves exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifid us starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE for sciatic and/or femoral nerves (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement for trunk extensors/multifidus starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Advanced functional training: curl-ups on unstable surface, trunk flexion sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, trunk extension sitting or standing on stable/unstable surface

35 lift head, arms and LE off table Intermediate training: curl-ups, curl-downs, diagonal curl-up, double knee to chest, pelvic lifts, bilateral straight leg raising/lowering, thoracic elevation, leg lifts, superman, quadratus lumborum side plank w/ added UE loading in PNF patterns, quadratus lumborum side plank progression Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, community, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, pushups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal

36 Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home postures at end range positions such as hyper extension, use common sense and follow good safety habits, review the HEP)

37 Acute/Subacute Low Back Pain with Related Cognitive or Affective Tendencies Symptoms: Acute or subacute low back and/or low back-related LE pain Impairments: One or more of the following: o Two positive responses to Primary Care Evaluation of Mental Disorders screen and affect consistent with an individual who is depressed o High scores on the Fear-Avoidance Beliefs Questionnaire and behavioral processes consistent with an individual who has excessive anxiety or fear o High scores on the pain Catastrophizing Scale and cognitive process consistent with rumination, pessimism, or helplessness Key Concordant Signs: Familiar symptoms of acute or subacute low back and/or low back-related LE pain along with presence of depression, fear-avoidance beliefs, and/or pain catastrophizing Physical Exams to Rule In: Trunk AROM, PA mobs for segmental mobility and symptom provocation, observation of aberrant motion, trunk muscle power and endurance tests, Management for Each Stage of Healing: PROM hip motions. Patient education and counseling to address specific classification exhibited by the patient (ie, depression, fear-avoidance, pain catastrophizing) **See the table below for details** Phases of Rehabilitation Intervention Kinesthetic awareness Proprioceptio n training of safe movement and postures Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Pelvic tilt: passive active assist active. Teach the patient to move his or her pelvis in an anterior and posterior pelvic tilt in a comfortable range Awareness of what (postures/movements ) makes symptoms better vs. worse Learn neutral spine (or bias) Basic Training/Controlled motion Phase Moderate to minimum protection Active spinal control in various positions supine, prone, quadruped, sitting, standing Dynamic maintenance of pain-free position with activities Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine in all functional activities Return to normal ADLs, activities, work, function

38 Mobility/flexibility Move, stretch, manipulate restricting tissues Lumbar PA mobilizations grades 1 and 2 for pain control Gentle passive stretching of tight musculature/tissue in pain-free range of low back and hips Lumbar PA mobilizations grade 3 for segmental mobility Active stretching of tight musculature/tissue and spinal movement into painful range for low back and hips Lumbar mobilizations and manipulation grades IV and thrust to increase segmental mobility Continue to stretch tight tissue and perform exercises/activities in painful/end range positions for low back and hips Muscle performance training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of TA and multifidus using The Stabilizer biofeedback device: hold 10 seconds x 10 repetitions TA: patient supine bent leg fallout with TA activation trunk extensors/multifidus: quadruped unilateral arm raise or unilateral leg extension exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table

39 Intermediate training: curl-ups, curl-downs, diagonal curl-up, double knee to chest, pelvic lifts, bilateral straight leg raising/lowering, thoracic elevation, leg lifts, superman, quadratus lumborum side plank Advanced functional training: curl-ups on unstable surface, trunk flexion sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, trunk extension sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, quadratus lumborum side plank progression Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, community, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid

40 adaptations, load position, ergonomic changes to work and home postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end range positions such as hyper extension, use common sense and follow good safety habits, review the HEP)

41 Chronic Low Back Pain with Related Generalized Pain Symptoms: Low back and/or low back-related LE pain with symptom duration for longer than 3 months Generalized pain not consistent with other impairment-based classification criteria presented in these clinical guidelines Impairments: One or more of the following: o Two positive responses to Primary Care Evaluation of Mental Disorders screen and affect consistent with an individual who is depressed o High scores on the Fear-Avoidance Beliefs Questionnaire and behavioral processes consistent with an individual who has excessive anxiety or fear o High scores on the pain Catastrophizing Scale and cognitive process consistent with rumination, pessimism, or helplessness Key Concordant Signs: Familiar symptoms of low back and/or low back-related LE pain lasting longer than 3 months and generalized pain not consistent with other impairment based classification criteria along with a presence of depression, fear-avoidance beliefs, and/or pain catastrophizing. Physical Exams to Rule In: Trunk AROM, PA mobs for segmental mobility and symptom provocation, observation of aberrant motion, trunk muscle power and endurance tests, PROM hip motions. Management for Each Stage of Healing: Patient education and counseling to address specific classification exhibited by the patient (ie, depression, fear-avoidance, pain catastrophizing) Low-intensity, prolonged (aerobic) exercise activities **See the table below** Phases of Rehabilitation Intervention Kinesthetic awareness Proprioceptio n training of safe movement and postures Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Pelvic tilt: passive active assist active. Teach the patient to move his or her pelvis in an anterior and posterior pelvic tilt in a comfortable range Awareness of what (postures/movements ) makes symptoms better vs. worse Learn neutral spine (or bias) Basic Training/Controlled motion Phase Moderate to minimum protection Active spinal control in various positions supine, prone, quadruped, sitting, standing Dynamic maintenance of pain-free position with activities Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine in all functional activities Return to normal ADLs, activities, work, function

42 Mobility/flexibility Move, stretch, manipulate restricting tissues Lumbar PA mobilizations grades 1 and 2 for pain control Gentle passive stretching of tight musculature/tissue in pain-free range of low back and hips Lumbar PA mobilizations grade 3 for segmental mobility Active stretching of tight musculature/tissue and spinal movement into painful range for low back and hips Lumbar mobilizations and manipulation grades IV and thrust to increase segmental mobility Continue to stretch tight tissue and perform exercises/activities in painful/end range positions for low back and hips Muscle performance training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of TA and multifidus using The Stabilizer biofeedback device: hold 10 seconds x 10 repetitions TA: patient supine bent leg fallout with TA activation trunk extensors/multifidus: quadruped unilateral arm raise or unilateral leg extension exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table

43 Intermediate training: curl-ups, curl-downs, diagonal curl-up, double knee to chest, pelvic lifts, bilateral straight leg raising/lowering, thoracic elevation, leg lifts, superman, quadratus lumborum side plank Advanced functional training: curl-ups on unstable surface, trunk flexion sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, trunk extension sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, quadratus lumborum side plank progression Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, community, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid

44 adaptations, load position, ergonomic changes to work and home postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end range positions such as hyper extension, use common sense and follow good safety habits, review the HEP)

45 McKenzie - Derangement Symptoms: Constant or intermittent pain in low back and referred buttock or LE symptoms Can be acute, subacute, or chronic with either a gradual or sudden onset. Variable symptoms with rapid changes. Centralization of symptoms only in this classification of MDT Impairments: Neurological: motor or sensory deficits, abnormal reflexes and dural signs Trunk range of motion loss obstructed in either flexion or extension Restrictions in joint segmental mobility Possible trunk lateral shift Pain during movement and end range pain. Key Concordant Signs: Familiar symptoms of constant or intermittent low back pain and referred buttock/le symptoms that are reproduced during either trunk flexion or extension and are centralized with the opposite movement Physical Exams to Rule In: AROM of trunk, PA mobs for segmental mobility, neurological screen, repeated test movements, sustained postures, slump test, straight leg raise, lower limb tension tests Management for Each See the table below for details Stage of Healing: Phases of Rehabilitation Intervention Kinesthetic awareness Proprioceptio n training of safe movement and postures Mobility/flexibility Move, stretch, manipulate restricting tissues Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Pelvic tilt: passive active assist active. Teach the patient to move his or her pelvis in an anterior and posterior pelvic tilt in a comfortable range Awareness of what (postures/movements ) makes symptoms better vs. worse Learn neutral spine (or bias) Posterior Derangement- Progression of forces: (type of progression dependent on patient tolerance and symptom presentation. Starting point different for each patient) Lying prone with arms relaxed at side lying prone in extension, elbows propped up underneath body extension in lying, Basic Training/Controlled motion Phase Moderate to minimum protection Active spinal control in various positions supine, prone, quadruped, sitting, standing Dynamic maintenance of pain-free position with activities Posterior Derangement- Progression of forces: (type of progression dependent on patient tolerance and symptom presentation. Starting point different for each patient) Lying prone with arms relaxed at side lying prone in extension, elbows propped up underneath body Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine in all functional activities Return to normal ADLs, activities, work, function Posterior Derangement- Progression of forces: (type of progression dependent on patient tolerance and symptom presentation. Starting point different for each patient) Lying prone with arms relaxed at side lying prone in extension, elbows propped up underneath body

46 patient props themselves up actively until elbows are fully extended extension in lying with selfoverpressure, lock elbows fully while exhaling and letting abdomen sag extension in standing varying degrees of extension in lying with clinician overpressure progressing towards end range extension passive extension mobilizations Posterior Derangement w/ lateral component Progression of forces: (type of progression dependent on patient tolerance and symptom presentation. Starting point different for each patient) Extension in lying (EIL) with hips off center away from pain EIL with hips off center with lateral overpressure by clinician side glide in standing (SGIS) rotation mobilization in extension rotation mobilization in flexion Anterior Derangement Progression of forces: (type of progression dependent on patient tolerance and symptom presentation. Starting point different for each patient) Flexion in lying (FIL) Flexion in sitting flexion in standing flexion in step standing flexion in extension in lying, patient props themselves up actively until elbows are fully extended extensio n in lying with selfoverpressure, lock elbows fully while exhaling and letting abdomen sag extension in standing varying degrees of extension in lying with clinician overpressure progressing towards end range extension passive extension mobilizations Posterior Derangement w/ lateral component Progression of forces: (type of progression dependent on patient tolerance and symptom presentation. Starting point different for each patient) Extension in lying (EIL) with hips off center away from pain EIL with hips off center with lateral overpressure by clinician side glide in standing (SGIS) rotation mobilization in extension rotation mobilization in flexion Anterior Derangement Progression of forces: (type of progression dependent on patient tolerance and symptom presentation. Starting point different for each patient) Flexion in lying (FIL) Flexion in sitting flexion in standing flexion in extension in lying, patient props themselves up actively until elbows are fully extended extensio n in lying with selfoverpressure, lock elbows fully while exhaling and letting abdomen sag extension in standing varying degrees of extension in lying with clinician overpressure progressing towards end range extension passive extension mobilizations Posterior Derangement w/ lateral component Progression of forces: (type of progression dependent on patient tolerance and symptom presentation. Starting point different for each patient) Extension in lying (EIL) with hips off center away from pain EIL with hips off center with lateral overpressure by clinician side glide in standing (SGIS) rotation mobilization in extension rotation mobilization in flexion Anterior Derangement Progression of forces: (type of progression dependent on patient tolerance and symptom presentation. Starting point different for each patient) Flexion in lying (FIL) Flexion in sitting flexion in standing flexion in

47 lying with clinician overpressure step standing flexion in lying with clinician overpressure step standing flexion in lying with clinician overpressure Muscle performance training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of TA and multifidus using The Stabilizer biofeedback device: hold 10 seconds x 10 repetitions TA: patient supine bent leg fallout with TA activation trunk extensors/multifidus: quadruped unilateral arm raise or unilateral leg extension exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidus starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Intermediate training: curl-ups, curl-downs, diagonal exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidus starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Advanced functional training: curl-ups on unstable surface,

48 curl-up, double knee to chest, pelvic lifts, bilateral straight leg raising/lowering, thoracic elevation, leg lifts, superman, quadratus lumborum side plank trunk flexion sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, trunk extension sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, quadratus lumborum side plank progression Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, community, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from

49 prolonged postures, avoid spinal postures at end range positions such as hyper extension, use common sense and follow good safety habits, review the HEP)

50 McKenzie - Dysfunction Symptoms: Intermittent low back pain. May have referred buttock and LE symptoms if there is an adherent nerve root. Pain caused by presence of adaptively shortened tissue and pain occurs when these tissues are stretched Chronic condition with a gradual onset unless ANR was caused by a trauma or injury Symptoms are consistent with no rapid changes Impairments: Trunk range of motion loss in either flexion or extension restricted Pain at end range movements of flexion or extension or in prolonged positions Positive dural signs with ANR Restrictions in joint segmental mobility Key Concordant Signs: Familiar symptoms of intermittent low back pain at end range flexion or extension during prolonged positions Familiar symptoms of LE pain and numbness, tingling, paresthesias for ANR Physical Exams to Rule In: AROM of trunk to end range, PA mobs for segmental mobility, sustained postures. For ANR: neurological screen, slump test, straight leg raise, lower limb tension tests, flexion in standing and flexion in lying. Management for Each See the table below for details Stage of Healing: Phases of Rehabilitation Intervention Kinesthetic awareness Proprioceptio n training of safe movement and postures Mobility/flexibility Move, stretch, manipulate restricting tissues Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Pelvic tilt: passive active assist active. Teach the patient to move his or her pelvis in an anterior and posterior pelvic tilt in a comfortable range Awareness of what (postures/movements ) makes symptoms better vs. worse Learn neutral spine (or bias) Flexion Dysfunction: Flexion in lying (FIL) Flexion in sitting flexion in standing flexion in step standing and possibly flexion in lying with clinician overpressure Extension Dysfunction: Lying prone with arms relaxed at side lying Basic Training/Controlled motion Phase Moderate to minimum protection Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Flexion Dysfunction: Habitual use of neutral spine in all functional activities Return to normal ADLs, activities, work, function Flexion Dysfunction: Flexion in lying (FIL) Flexion in sitting flexion in standing flexion in step standing and possibly flexion in lying with clinician overpressure Extension Dysfunction: Lying prone with arms relaxed at side Flexion Dysfunction: Flexion in lying (FIL) Flexion in sitting flexion in standing flexion in step standing and possibly flexion in lying with clinician overpressure Extension Dysfunction: Lying prone with arms relaxed at side

51 prone in extension, elbows propped up underneath body extension in lying, patient props themselves up actively until elbows are fully extended extension in lying with selfoverpressure, lock elbows fully while exhaling and letting abdomen sag extension in standing and possibly varying degrees of extension in lying with clinician overpressure progressing towards end range extension and possibly passive extension mobilizations Side Gliding Dysfunction: Progressive side bending into direction of restriction to improve ROM ANR Dysfunction: Flexion in lying extension in lying flexion in step standing flexion in standing *** Progressive movement in direction of restriction (flexion, extension, side gliding, ANR). Improve motion gradually and assess symptoms during and after motion. Exercises performed 10 times every 2-3 waking hours. Move into ROM where symptoms are reproduced*** lying prone in extension, elbows propped up underneath body extension in lying, patient props themselves up actively until elbows are fully extended extensio n in lying with selfoverpressure, lock elbows fully while exhaling and letting abdomen sag extension in standing and possibly varying degrees of extension in lying with clinician overpressure progressing towards end range extension and possibly passive extension mobilizations Side Gliding Dysfunction: Progressive side bending into direction of restriction to improve ROM ANR Dysfunction: Flexion in lying extension in lying flexion in step standing flexion in standing *** Progressive movement in direction of restriction (flexion, extension, side gliding, ANR). Improve motion gradually and assess symptoms during and after motion. Exercises performed 10 times every 2-3 waking hours. Move into ROM where symptoms are reproduced*** lying prone in extension, elbows propped up underneath body extension in lying, patient props themselves up actively until elbows are fully extended extensio n in lying with selfoverpressure, lock elbows fully while exhaling and letting abdomen sag extension in standing and possibly varying degrees of extension in lying with clinician overpressure progressing towards end range extension and possibly passive extension mobilizations Side Gliding Dysfunction: Progressive side bending into direction of restriction to improve ROM ANR Dysfunction: Flexion in lying extension in lying flexion in step standing flexion in standing *** Progressive movement in direction of restriction (flexion, extension, side gliding, ANR). Improve motion gradually and assess symptoms during and after motion. Exercises performed 10 times every 2-3 waking hours. Move into ROM where symptoms are reproduced***

52 Muscle performance training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of TA and multifidus using The Stabilizer biofeedback device: hold 10 seconds x 10 repetitions TA: patient supine bent leg fallout with TA activation trunk extensors/multifidus: quadruped unilateral arm raise or unilateral leg extension exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidus starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Intermediate training: curl-ups, curl-downs, diagonal curl-up, double knee to chest, pelvic lifts, bilateral straight leg raising/lowering, thoracic elevation, leg lifts, superman, quadratus lumborum side plank exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidus starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Advanced functional training: curl-ups on unstable surface, trunk flexion sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, trunk extension sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, quadratus

53 lumborum side plank progression Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, community, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end

54 range positions such as hyper extension, use common sense and follow good safety habits, review the HEP)

55 McKenzie - Postural Symptoms: Acute, intermittent, localized low back pain during sustained end-range positioning Condition is a gradual onset Impairments: Lumbar pain experienced during prolonged static loading at end range (Physical examination normal with no reproduction of symptoms in response to single or repeated movements. Normal range of motion) Poor static posture (standing or seated) Key Concordant Signs: Familiar symptoms of localized low back pain that are reproduced during sustained static end-range positioning Physical Exams to Rule In: Observation of posture, static loading at end range positions Management for Each Stage of Healing: See the table below for details Phases of Rehabilitation Intervention Kinesthetic awareness Proprioceptio n training of safe movement and postures Mobility/flexibility Move, stretch, manipulate restricting tissues Early Training/Protection Phase Maximum to moderate protection of injured area, pathologically involved tissues, or painful region Pelvic tilt: passive active assist active. Teach the patient to move his or her pelvis in an anterior and posterior pelvic tilt in a comfortable range Awareness of what (postures/movements ) makes symptoms better vs. worse Learn neutral spine (or bias) ***Mobility and flexibility should be WNL in examination for postural syndrome. Continue to give postural education and stretch any tissues that you find restricted in examination*** Basic Training/Controlled motion Phase Moderate to minimum protection Active spinal control in various positions supine, prone, quadruped, sitting, standing Dynamic maintenance of pain-free position with activities ***Mobility and flexibility should be WNL in examination for postural syndrome. Continue to give postural education and stretch any tissues that you find restricted in examination*** Intermediate to Advanced Training/Return to Function Phase Minimum to no protection Habitual use of neutral spine in all functional activities Return to normal ADLs, activities, work, function ***Mobility and flexibility should be WNL in examination for postural syndrome. Continue to give postural education and stretch any tissues that you find restricted in examination***

56 Muscle performance training (deep muscles for segmental stability, global muscles for general stability) Muscle endurance Strength and power Activation of TA and multifidus using The Stabilizer biofeedback device: hold 10 seconds x 10 repetitions TA: patient supine bent leg fallout with TA activation trunk extensors/multifidus: quadruped unilateral arm raise or unilateral leg extension exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Intermediate training: curl-ups, curl-downs, diagonal curl-up, double knee to chest, pelvic lifts, bilateral straight leg raising/lowering, thoracic elevation, leg lifts, superman, quadratus lumborum side plank exercises (lift bent leg to 90 hip flexion, slide heel, lift straight leg to 45 ) with patient supine for TA progressing: opposite LE on mat; bent leg fall out opposite LE on table holding opposite 90 of hip flexion with UE hold 90 of hip flexion (no UE assistance) bilateral LE movement exercises for trunk extensors/multifidu s starting quadruped than progressing to prone. Quadruped progression: flex one UE extend one LE by sliding along table Extend one LE and lift off table flex one UE and extend contralateral LE. Prone progression: extend one LE extend both LE lift head, arms and LE off table Advanced functional training: curl-ups on unstable surface, trunk flexion sitting or standing on stable/unstable surface w/ added UE loading in PNF patterns, trunk extension sitting or standing on stable/unstable surface w/ added UE loading in PNF

57 patterns, quadratus lumborum side plank progression Cardiopulmonary Endurance Aerobic training Only if tolerated with maximum protection in position of comfort. Select type of aerobic training appropriate for the patient Low to moderate intensity with moderate to minimal protection. Select type of aerobic training appropriate for the patient Use activities that emphasize spinal bias High-intensity (target heart rate), multiple times per week. Select type of aerobic training appropriate for the patient Functional Activities Body mechanics Skill in home, community, work, recreation, sport activities Safe postures for recumbent, sitting and standing Stable-spine techniques while rolling over, moving supine to sit, sit to stand Preparation for functional activities while maintaining stable spine: basic exercise techniques (modified bridging exercises, push-ups with trunk stabilization, wall slides, partial lunges, partial squats and steps, walking against resistance, quadruped forward/backward shifting, squatting and reaching, shifting weight and turning) Patient education on body mechanics and environmental adaptations, load position, ergonomic changes to work and home Intermediate to advanced exercise techniques for functional training while maintaining stable spine (repetitive lifting, repetitive reaching, repetitive pushing and pulling, rotation or turning, transitional movements, transfer of training Endurance and strengthening activities that replicate return to desired activities of patient Patient education and practice for prevention (avoid postures that brings on pain, taking breaks from prolonged postures, avoid spinal postures at end

58 range positions such as hyper extension, use common sense and follow good safety habits, review the HEP)

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