Movement Rehabilitation Presentation

Case Study 4: Boris Backpain

Group Members

Tracy Auld 0275019 Sal Bisignano 0274987 Kylie Knudsen 0275054

Case StudyBoris is a 40 year old male, divorced with 3 children, who live with him every second week and owns a dog. He works as a warehouse manager for an industrial supply company where he administers incoming supplies, stores them and distributes the supplies using truck transportation. Fifty percent of his time he is in the office and the rest out in the warehouse driving a fork lift and directing the loading of materials. Two months ago Boris experienced pain in his lower back, hip and thigh posteriorly after a heavy night on the dance floor with his wife. The next morning he was unable to extend his trunk and had to sit and walk flexed forward. He was taken to the hospital where he was treated with muscle relaxants, anti inflammatory drugs and referred to an orthopedic back specialist. He was referred for an MRI scan which indicated a prolapsed disc but no vertebral abnormality. Musculoskeletal retraining by a physio then an exercise based therapy program was prescribed. This is the second time he has experienced this kind of injury. Boris is 220lbs and 5ft7in. Has been inactive all of his life except in high school. He has worked in physical and manual labor jobs all his life and is naturally strong in the upper body. He is overweight with most of the weight around his mid section. He also likes to eat and cook gourmet meals, drink imported beer, watch football, and fish as a recreation. He is actively involved in transporting his children who are also involved in competitive sport. Boris has completed his treatment for the acute stages of back rehab and is now ready for the development of range of motion and strengthening of the core musculature. He is currently working 3 days a week and experiences fatigue and discomfort at the end of the day. He has also been diagnosed with high blood pressure and high cholesterol, plus he has a family history of heart disease. You have been directed to get Boris back to full function so that he can resume his normal life process.

Background Information Occupation: warehouse manager Physical activity level: manual labor work, sedentary

on spare time Physical health: overweight, high blood pressure,

high cholesterol Medical diagnosis: prolapsed intervertebral disc Physical complaints: pain referral into back, hip and

hamstring area Diet: alcohol consumption high, high saturated fat

foods

Rehab Approach

Get Boris back to normal range of motion Increase his endurance to get through an

entire work day Strengthen core muscles Approach with prescription of flexibility and

strength exercises and functional ability activities

Important Information Before Rehab Begins Medical history shows that he has high blood

pressure and high cholesterol- his doctor must give clearance before exercise is to begin

Medical history also shows that the patient has relapsed in a previous exercise program from a similar injury- motivation is key to success of program

Complete a Par Q (as seen on the next slide) Allergies? None present. Medications being taken that pertain to injury and

those that do not. Boris is still taking anti inflammatory medications.

Has the patient been released from the rehabilitation with a physiotherapist/occupational therapist. Yes

Par-Q

Communication The patient must have a say in goal setting. A therapist must address any fears or personal

barriers that may hinder the patient’s recovery. What are the barriers that the patient is faced with

during day to day activities. How willing is the patient to commit to the

prescription in order to recover. Explain the Borg Scale of Perceived Levels of Pain Explain the patient’s injury in a way that is

comprehensive to the patient.

Borg’s Rate of Perceived Exertion Scale

1 6 No exertion at all 7 Extremely light 8 9 Very light 10 11 Light 12 13 Somewhat hard 14 15 Hard (heavy) 16 17 Very hard 18 19 Extremely hard 20 Maximal exertion

Prolapsed DiscThe disc that is found in between the vertebrae bones of the back has prolapsed. This means that the gel-like substance, or nucleus pulposus, found in the middle of the disc has been squished out. The area posterior to the disc and bodies of the vertebrae houses the spinal cord. When the disc herniates, the contents of the disc, specifically the nucleus pulposus, are squished into the area where the spinal cord is found. It can also squish into the area where nerves that give rise to sensation in the body exit the spinal canal. If these nerves are constricted, pain in the area where the nerves innervate or weakness may ensue.

Osteology of Effected Area The vertebral column consists of bone and connective tissue. Its function is to surround the spinal cord and protect it. The length of the column is about 71 cm in the average adult male, and 61cm in the average adult female. It serves as an attachment for the ribs, pelvic girdle, and muscles of the back. Typically the vertebral column consists of 26 vertebrae. Vertebrae 1-7 are called the cervical vertebrae. These are the vertebrae of the neck region and attach to

the cranium. Vertebrae 8-19 are called the thoracic vertebrae. These vertebrae provide attachment sites for the ribs. Vertebrae 20-25 are called the lumbar vertebrae. These vertebrae are found from the end of the ribs until

the line where the iliac crests meet. Inferior to the lumbar vertebrae is the sacrum. The sacrum consists of five fused vertebrae, that are fused

in the childhood years. The final portion of the vertebral column is called the coccyx. Relative to the front of the body, the cervical and lumbar vertebrae have a convex curve(bulging). The thoracic and sacral vertebrae have a concave curve(cupping in). Between the bodies of adjacent vertebrae from the second cervical vertebra to the sacrum are

intervertebral discs. Intervertebral discs consist of an outer fibrous ring composed of fibrocartilage, and an inner soft, highly

elastic substance called nucleus pulposus. These discs form strong joints, which permit various movements of the vertebral column, and absorb

compression forces and minimally other related forces of the vertebral column. Under compression they flatten and broaden. With age the nucleus pulposus hardens and becomes less elastic.

Myology of Effected Area Spinalis group: spinalis capitis, spinalis cervicis, spinalis thoracis. Acting

together they extend the vertebral column of their respective region. Transversospinalis group: semi spinalis capitis, semispinalis cervicis,

semispinalis thoracis, multifidus, and rotatores. Semispinalis capitis- acting together they extend the head. Acting individually

they rotate the head. Semispinalis cervicis and semispinalis thoracis- acting together they extend the

vertebral column of their respective regions. Multifidus- Acting together they extend the vertebral column. Acting individually

they laterally flex the vertebral column, and rotate the head. Rotatores- Acting together they extend the vertebral column. Acting individually

they rotate the vertebral column. Segmental group: The segmental group consists of the interspinales. And the

intertransversarli. Interspinales-Acting together , they extend the vertebral column. Acting

individually they stabilize the vertebral column during movement. Intertransversarli- Acting together they extend the vertebral column. Acting

individually they laterally flex the vertebral column.

Myology of Effected Area

Myology of Effected Area The Erector spinae is very important in controlling flexion, lateral

flexion, and rotation. The erector spinae is the chief extensor of the back and is the largest

muscle mass on the back. The erectore spinae is composed of three different muscle groups: the

iliocostalis group, lingissismus group, and spinalis group. The erector spinae Originates on: the superior six ribs, inferior six ribs,

illiac crest, transverse processes of superior four thoracic vertebrae and articular processes of inferior four cervical vertebrae, transverse processes of 4th and 5th thoracic vertebrae, transverse processes of lumbar vertebrae, ligamentum nuchae and spinous processes of the seventh cervical vertebrae, and spinous processes of superior lumbar and inferior thoracic vertebrae.

The erector spinae inserts on: transverse processes of fourth and sixth cervical vertebrae, superior six ribs, inferior six ribs, transverse processes of second to sixth cervical vertebrae, mastoid process of temporal bone, transverse processes of all thoracic and superior lumbar vertebrae and ninth and tenth ribs, occipital bone, spinous process of axis, and spinous processes of superior thoracic vertebrae.

Neurology of Effected Area The Spinal cord is the major nerve that innervates the

vertebral column. It is roughly cylindrical in shape, but is flattened slightly in its anterior posterior dimension.

In adults the spinal cord runs from the medulla oblongata, to the superior border of the second lumbar vertebra.

The spinal cord is surrounded by extensions of dural sheath called denticulate ligaments. These denticulate ligaments extend all along the length of the spinal cord to support and protect the spinal cord against sudden displacements.

Since the pain the patient is having is in the lumbar region we will focus on the lumbar and sacral nerves that branch out of the spinal cord.

The First group of nerves come from the Lumbar plexus. The lumbar plexus branches off the spinal cord from L1-L4.

The following nerves are the nerves that originate from the lumbar plexus: Iliohypogastric nerve, ilioinguinal nerve, genitofemoral nerve, lateral femoral cutaneous nerve, femoral nerve, obturator nerve.

The next group of nerves that branch off the spinal cord are called the sacral plexus.

The sacral plexus extends from L4-S4. The sacral plexus nerves that branch off the spinal cord between L4-S4. The nerves that originate from the sacral plexus are: superior gluteal nerve, inferior gluteal nerve, the sciatic nerve (branches off into common fibular nerve, and tibial nerve), the posterior cutaneous nerve of thigh, and the pudendal nerve.

Postural Assessment

A brief scan of posture should be incorporated prior to range of motion testing.

Posterior View Head: erect or twisted and turned Shoulders: level or is one slightly higher Spine: straight or does it appear deviated or

scoliotic Hip: level or is one higher Feet: pointed straight ahead or outward

Postural Assessment

Lateral View Neck: is it erect or poked forward Upper back: normally rounded or kyphotic Trunk: erect or inclined posteriorly Abdomen: flat or protuding and sagging Lower back: normally curved or markedly

lordotic

Types of Posture

Good Type A: relaxed, faulty posture Type B: kyphosis or lordosis Type C: sway back Type D: flat back Type E: round back Figure 14-3. Types of faulty posture. (From McMorris, R. O.:Pediatr. Clin. North

Am. 8:217, 1961.)

Range of Motion Testing of BackTrunk Flexion And Extension Of The Lower Back The patient stands with feet shoulder width

apart. The patient then flexes the trunk forward to the

maximal motion. A tape measure is used to record trunk flexion

and extension. The therapist finds S2 and measures a point

from S2 to 10cm above the S2. Both of these points are marked with a marker.

The patient flexes to his/her maximal point and a measurement is taken between the two lines made previously.

The difference between the two measurements is the lumbar flexion.

Extension can also be measured. The patient has the same two points marked out however, the patient then places his/her hands on the illiac crests and extends to their maximal point.

The difference between these two number is the maximal extension for the lumbar spine.

Normal range is from 0-80º or 10 cm.

Range of Motion Testing of BackExtension of the Thoracolumbar spine The patient lies prone on the table with a pillow under

the abdomen. The hands are positioned at the end of the table.

A strap is placed over the pelvis to stabilize. The patient extends the elbows to raise the trunk and

extend the thoracolumbar spine. This ROM test is measured with a tape measure. The tape measure is used to measure the distance

between the suprasternal notch and the table at the end of full extension.

Trick movement: Lifting of the pelvis. Normal range is 0-80º or 10 cm

Range of Motion Testing of BackTrunk Lateral Flexion The patient stands with the

feet shoulder width apart with hands at their side. The patient laterally flexes the trunk to the limit of motion.

A tape measure is used to measure the distance between the third digit and the floor, before the activity and then during activity.

Trick movement trunk flexion, trunk extension, hip and knee flexion.

Normal range is 0-35º

Range of Motion Testing of BackTrunk Rotation The patient sits on the table with the feet being

supported by a stool. Arms are crossed in front of the chest. The therapist uses both hands to stabilize the pelvis. The patient rotates the trunk to the limit of motion. The measurement used is an estimation by the

therapist. Trick Movement: Trunk flexion, trunk extension, and shoulder abduction. Normal range is 0-45º

Range of Motion Testing of HipHip FlexionPROM Assessment Patient lies supine on table with the injured leg

in a neutral position. The other leg may be flexed or extended.

The therapist stabilizes the pelvis with one hand and places the distal hand on the posterior side where the distal portion of the femur is.

While maintaining stabilization of the pelvis, the therapist applies slight traction to move the femur anteriorly to the limit of hip flexion.

When using the goniometer to measure hip flexion, place the axis over the greater trochanter. The stationary arm should run parallel to the midaxillary line of the trunk. The moveable arm should run parallel to the femur, pointing to the lateral epicondyle.

AROM This assessment is the same as the PROM

without assistance Trick Movement: Posterior tilt of the pelvis and

flexion of the lumbar spine. Normal range of motion is 0-120º

Range of Motion Testing of HipHip ExtensionPROM The patient lies prone on the table, both hips and legs are in a neutral

position with the feet lying over the edge of the table. The therapist stabilizes the pelvis with the proximal hand while placing

the distal hand on the anterior portion of the distal femur. The therapist then moves the femur posteriorly until full range of motion

is achieved. When using the goniometer the stationary arm lies parallel to the

midaxillary line of the trunk. The moveable arm lies parallel to the femur pointing toward the lateral epicondyle. The axis is held over the greater trochanter.

AROM This assessment is the same as PROM without assistance. Trick movement: The pelvis may tilt anteriorly and extension of the

lumbar spine. Normal range of motion is 0-30º

Range of Motion Testing of HipHip AbductionPROM The patient lies supine on the table with the lower

extremities in anatomical position and the pelvis lies level with the lower extremity.

The therapist places the proximal hand on the pelvis to stabilize it, and the distal hand on the medial aspect of the distal femur.

The therapist then moves the femurs away from the body to the limit of abduction. The end feel of hip abduction should be firm.

When using the goniometer the axis is placed over the ASIS of the side being measured.The stationary arm runs along the two ASIS’s. The moving arm is placed anteriorly along the longitudinal axis of femur.

The goniometer measurement will start at 90degrees. Assume 90 degrees is 0 degrees.

AROM This measurement is the same as PROM accept it is

without assistance. Trick Movement: External rotation and flexion of the

hip. Normal range of motion is 0-45º

Range of Motion Testing of HipHip AdductionPROM The patient lies supine on the table with the hip and

lower extremities in anatomical position. The leg that is not being tested is abducted to allow

full ROM of the leg being tested. The therapist places the proximal arm on the pelvis

to stabilize it and the distal arm on the posterior aspect of the distal portion of the femur.

The therapist then moves the lower extremity to the limit of hip adduction.

The end feel may be soft or firm. When using the goniometer the axis is placed over

the ASIS of the side being measured. The moving arm is placed anteriorly along the longitudinal axis of femur.

The goniometer measurement will start at 90degrees. Assume 90 degrees is 0 degrees.

AROM This measurement is the same as PROM accept

without assistance. Trick Movement: Internal rotation. Normal range of motion is 0-30º

Muscle TestingStraight Leg Raising Test Patient begins by lying in a supine position on the table. The therapist then passively lifts the patient’s leg by supporting

under the calcaneous bone. The other hand is placed over the anterior aspect of the patient’s involved leg in order to maintain a straight leg position.

Lift the leg to approximately 80º If pain occurs lower the leg and dorsiflex the ankle. If there is a reaction to dorsiflexion then have the patient locate

the pain as precisely as possible. If there is no pain upon dorsiflexion, it is an indication of tight hamstrings.

Muscle Testing

Well Leg Straight Leg Raise Test This test is the active version of the straight

leg raise test and follows generally the same procedure but with active flexion at the hip.

If back or sciatic pain occurs on the opposite side as being flexed, it is an indication of a prolapsed disc in the lumbar area.

Muscle TestingHoover TestThis test is important because the patient may be less

than motivated in performing these tests. The interview prior to the beginning of any program can indicate level of motivation.

The procedure for the well leg straight leg raise test is repeated. The therapist holds both calcaneus bones while the movement is occurring.

If there is no downward pressure being felt on the opposite leg that is being flexed at the hip, the patient is not likely trying.

Muscle Testing

Kernig TestThis test is used to indicate meningeal irritation,

nerve root involvement, and irritation of the dural coverings around the spinal cord.

The patient lays supine and places their hands behind their head. The patient then flexes their cervical spine to produce the action of bringing the chin to the chest.

If there is pain present, it indicates any of the above problems discussed.

Muscle Testing

Thomas TestThis test is used to indicate whether a patient has hip contractures. Boris has been required to maintain a flexed position for a length of time.

The patient lies supine on the table with the pelvis level and square to the trunk.

The therapist stabilizes the lumbar region by placing their hand under the lumber spine.

The patient flexes the knee and hip to the chest. The therapist notes the point where the back flattens.

This point is important to asses pure hip joint range.

Muscle Testing

Thomas Test (cont’d) The thigh should rest against the abdomen The patient then flexes the other leg. Extend the first leg that was flexed onto the

table. If the leg does not rest flat, a contracture may be present.

Expectations of Exercise Prescription

         •Patient’s goals analysis

•Motivation

•Weight management

•Prevention techniques

•Exercise Program

•Functional Activities  

Patient Goals Analysis

What does the patient want to get out of the program?

 

Boris wants to achieve:

Full range of motion

Increased Endurance

Decreased/eliminated pain

Reduced body weight

Learn how to prevent it

Motivation

• Boris has already discontinued one exercise program.

• Must find out why the client did not continue with program

• Why he quit:

Too busy with work and kids to get to the gym

Too tired after work

Motivation• In order for him to continue with a new program he will have to be convinced that it is worth his time

•  Benefits of physical activity:

Feel more energetic

         Decreased risk of heart disease

         Decreased risk of type II diabetes

         Weight management

        Improved Posture

        Sleep better

        DECREASE STRESS ON SPINE IN DAILY LIVING!!

Weight Management

• Recommendation to nutritionalist

•  Increase physical activity with exercise program:

Strength Training Program

       Walking Program

Prevention Techniques Understanding Pain Progression

• Why is it important?

Understanding the progression of pain or pain patterns associated with the condition will allow for early recognition of reoccurrence and avoidance of activities that cause irritation

• Pain associated with a prolapsed disc

Pain tracking depends on the severity of the bugle. Generally the pain starts locally (just around the disc) and migrates down the posterior side of the leg as the condition worsens ( peripheralization). The farther the pain is down the leg, the more severe the bulge is

Prevention Techniques

Pain Centralization (condition improving)

Pain Peripherilazation (condition worsening) McKenzie Institute International,p 42

Prevention Techniques

Pain During Rehab

•During Rehab the pain should migrate out of the leg and into just the back (centralization)  

•This may make the localized pain in the back feel worse for a while, but ultimately the condition is closer to recovery.

•Important: During stretching or physical activity it is important to stop immediately if pain in the leg migrates towards the foot, pain returns in the leg, or localized pain becomes intolerable, as it may be worsening the condition by applying more pressure to the nerve.

Prevention Techniques

Sitting Position

• Important to have proper posture when sitting to reduce stress on the back

• Proper sitting position is:

Feet flat on the floor

Knees bent at 90

Back straight and supported

Donkin,1986,p 51

Prevention Techniques

Sitting Position continued. . .

• Ways to help correct old habits

Back Rest Support (obusform, back roll, towel rolled up)

Strengthen core muscles

• Recommendation made that Boris try a back support for his office at work and for his car

Prevention TechniquesStretching

•When sitting for long periods it is important to stretch out your back and your legs

• Try to stretch at least every 15 minutes.

•Every 30 minutes get up to stretch and walk around for a couple of minutes

Donkin 1986,p30

Prevention Techniques

Resting

Lying down on your back or lying with your feet elevated takes the compressive forces off of the spine. This will provide some relief for irritated discs.

If you have time at noon or on coffee break, take 5 minutes to lie down on a bench or a couch

When you get home lie down for 10-15 minutes before driving children or making dinner

Prevention TechniquesProper Lifting Technique

• Be close to the object that is being lifted

• Plant feet firmly on the ground in a wide stance

• Allow the back to maintain the natural curve of the lumbar spine

• Bend the knees to get to the load

• Lean back and extend the knees to lift

• Lifting should be a smooth movement rather than a jerky one

• If performing a rotational movement when under load, turn the feet rather than the back.

Prevention Techniques

Proper Lifting Technique

McKenzie 2005, p 28

Prevention Techniques

Other Lifting Tips:

•Try not to lift heavy loads in the morning when your discs are swollen

•Walk around before lifting after sitting

•Stretch before and after lifting (standing extensions)

Prevention Techniques

Sneezing/coughing

• Sneezing and coughing put a lot of pressure on the discs, especially if they induce forced flexion, and they can be very painful

• To reduce pain:

Lean back (put back into extension)

Bend knees

Prevention Techniques

Sleeping soundly

•Getting a good sleep is important to everyone’s health.

•It can be difficult because of back pain

•Ways to minimize discomfort while sleeping:

- Check you mattress. Should be supportive and not sagging

- May want to avoid prone positions

- May want to try a lumbar roll McKenzie 2005, p73

Exercise Program

This programs progression is based on pain levels versus time passed. This allows Boris to work at a pace at which he is comfortable, so that he does not feel intimidated by the program, as well it allows for the proper time for his disc to centralize.

 The Walking Program is part of Boris’s weight management but it is also part of his rehabilitation program. He can start anytime when can tolerate light walking for short distances. This is usually after approximately the 5th day after injury depending on the severity of the bulge.

The phases of the walking program are the same as in the exercise program so progressions can happen together.

Exercise Program-summary Summary:

Phase 1: While experiencing severe pain

Range of motion until pain is localized

Mainly passive extension stretches, no flexion

 Phase 2: When pain is centralized Add range of motion of the legs (hamstrings, hip flexors, plantar flexors), and unloaded back flexion

minimal isometric core strengthening

Phase 3: 2- 3 Weeks after pain is gone or not interfering with daily activity

Begin strength exercises. Focus on core strength for spinal support and legs for lifting.

Walking Program

3 Phase Walking Program• Benefits

- Low intensity means less chance of irritation or re-injury

- Can be done anywhere, anytime

        - Assists in weight management

         - Builds strength in the core and lower limbs

         - Stretches legs (hip flexors, plantar flexors)

         - Appropriate at all stages of rehab

Walking Program

Phase 1: While experiencing severe pain

Intensity: low

Duration: Short

Frequency: High

Note: Short, slow paced walks spaced out through out the day will provide relief to long periods of sitting for the back and increased activity levels without causing irritation. All three categories are left up to the patient as will vary greatly depending on pain.

Walking Program

Phase 2: When pain is centralized

Intensity: Increase to a comfortable walking pace (11-12 on Borg Scale)

Duration: Aim for 40 minutes

Frequency: Aim for 4-5 times a week

Note: Duration is cumulative. Small bouts of exercise consisting of minimum 10 minutes may be completed throughout the day and totaled at the end or can all be done at once. However, it is recommended that for the purpose of weight loss 2 walks a week be kept 20-30 minutes long.

Walking Program

Phase 3: 2- 3 Weeks after pain is gone or not interfering with daily activity

Continue with current program but try increasing the intensity sometimes to include moderate effort walks (brisk, Borg scale of 13-15).

Continue adding in longer walks when possible

Walking Program

Tips to fit it in: it only has to be 10 minutes at a time!

- Walk around buildings while waiting for children to finish their sporting activity instead of watching the whole game

-Take a walk at lunch hour

-Park at the back of the lot at work, or just down the road (that is 20 minutes already! There and back)

-Take the stairs (they count for more because they are harder!)

Exercise Program – phase 1Focus: Localize pain to lower back

 

Exercise Description Picture Sets Reps/time

Prone Extension on Elbows

- Lie prone (on stomach)- Support weight of upper body on your elbows bent at 90- Allow your back to relax (sag)

  Multiple times daily

Hold for 5 minutes

Passive Prone Full Extension

- Lie prone- Position hands under shoulders- Press up to raise top half of body- Let back relax

  -5-10 X/ session-5-10 X/ day

Hold for 20-30 sec

Exercise Program- phase 2

 

Exercise Description Picture Sets Reps/time

Active Prone Full Extension

- Lie prone- Position hands under shoulders- Press up to raise top half of body- Let back relax- Actively force lordisis (push belly button into the ground)

  -5-10 X/ session-2-3 X/ day

Hold for 20-30 sec

Angry Cat -Begin on hands and knees with back in neutral-Arch back up (push belly button to ceiling) and tuck in chin(relax and move to old horse)

  -5-10 X/ session-2-3 X/ day

Hold for 20-30 sec

Old Horse - Begin on hands and knees with back in neutral- Relax back - Push back into exaggerated lordosis (belly button to floor)(Relax and move to angry cat)

  -5-10 X/ session-2-3 X/ day

Hold for 20-30 sec

(Variation) Can be done standing, place hands on table or counter top instead of floor

     

Seated Flexion - Begin on hands and knees- Slowly lower Buttock back onto feet and drop chin to chest- Slide hands forward on floor- Reach forward as far as you can pushing chest to floor

  -5-10 X/ session-2-3 X/ day

Hold for 20-30 sec

Exercise Program- phase 2 cont. . .

 

Exercise Description Picture Sets Reps/time

Supine Hamstring Stretch on Back ( also stretches hip flexors)

-Patient lies supine with one leg extended -Bring other knee towards chest in a flexed position (this may be enough to feel a stretch)-Hands clasp at back of thigh-To increase level of stretch once the leg is fully flexed, straighten the knee as far as you can -To increase the level of the stretch again, have the foot dorsi flexed.(repeat with both legs)

  - 4 X/ session,- 2-3 X/ day

Hold for 10-15 sec

Calf Stretch - palce hands one the wall- one foot close to the wall the other extended behind- straighten extended leg keeping heel flat on the floor

-10-15 X/ session-2-3 X/ day

Hold for 10-15 sec

Tummy Tuck - Sit up straight - Contract abdominal muscles - Can push into a back rest if available (can be done while at work or driving in the car)

  -10-15 X/ session-2-3 X/ day

Hold for 10-15 sec

Exercise Program-phase 3

• Continue with phase 2 stretches 4-7 days a week (do not have to do all of them every time)

•Continue with all preventative measuresExercise Description Picture Sets Reps/time

Lean Backs - Sit in on edge of chair of bench- Tighten abdominal- Lean back slowly keeping back straight- return to upright

  -15-20 X/ session-2-3 X/ day- 4-6/week

Hold for 10-15 sec

Tummy Tuck - Sit up straight - Contract abdominal muscles - Can push into a back rest if available (Can be done while at work or driving in the car)

  -10-15 X/ session-2-3 X/ day- 4-6/week

Hold for 10-15 sec

Crunches on the Ball

- Lie with back over the ball - Curl up bringing shoulder blades off the ball 

  -10-30 X/ session-1/ day- 2-3/week

Hold for 10-15 sec

Exercise Program-phase 3 cont. . . Exercise Description Picture Sets Reps/time

Wall Sit - Stand with back to the wall and feet out in front.-Squat so that there is a bend in the hips and knees-Knees should remain over ankle -Don’t bend more than 90- Keep core tight when performing -- Work up to one leg at a time only—* Add ball behind back for added difficulty

2-3 sets 2-4 times a week

10-15

Seated Leg Raise - While seated keep one foot flat on floor and extend the other from the knee* Progress to extended knee with lifting thigh off chair slightly (Can do while at work)

  2-3 sets 2-4 times a week

10-15

Standing Calf Raise

- Stand with feet shoulder width apart- Rise up onto toes as high as possible then return to flat feet slowly- Body weight should be equally distributed* Stand on one foot to increase resistance

2-3 sets 2-4 times a week

10-15

Superman - Lie prone- Arms extended over head- Lift one arm and opposite leg off ground - Keep core tight

  2-3 sets 2-4 times a week

10-15

Functional Ability

Correct Lifting Technique

• Practice the correct lifting technique (refer to slide 50&51) using various loads.

• Begin with a light small load and focus on technique

- Pick the object up from the floor and place it down on a table behind you

-remove from the table and return to the floor

•Increase load weight as skill improves

Functional Activities

Lifting an Object from Different Heights Have the patient begin by picking an object up off of

a hip height table and placing in on another hip height table. Be sure to maintain correct lifting technique.

Different variations as a program progresses include picking up the object at a lower height and placing it at a hip height. They can also perform the reverse.

The weight and size of the object can also be varied as the patient progresses through the exercise prescription program.

Functional Activities

Lifting an Object Overhead The therapist asks the patient to pick up an object

from a hip height table and file it in an above shelf. A low height should be used first and then increase

as the patient progresses. A low weight should be used first and then increase

as the patient progresses. This activity is used to mimic any filing activities Boris

performs in the office.

References Canadian Society for Exercise Physiology. (1998). Canada’s physical

activity guide to healthy active living. Canada: Health Canada.

Clarkson HM.(2000). Musculoskeletal Assessment: joint range of motion and manual muscle strength (2nd ed). USA: Lippincott Williams & Wilkins.

 Donkin DC. (1986). Sitting on the job: how to survive the stresses on sitting down at work- a practical handbook. Boston: Houghton Mifflin Company.

Houglum PA. (2005). Therapeutic Exercise for musculoskeletal injuries(2nd ed). USA: Human Kinetics.

 McKenzie R.(2005). Treat your own back. Waikanae, New Zealand: Spinal Publications.

 McKenzie R. Mechanical diagnosis and theraphy: part A, the lumbar spine. Canada: The McKenzie Institute.

Oatis CA.( 2004). Kinesiology: the machanics and pathomechanics of human movement. USA: Lippincott Williams & Wilkins.