Back Injury prevention – Exercise Program Module - 12 Back Injury prevention – Exercise Program

Key Points to start an exercise regime Correct Interpretation of Physical examination and diagnostic findings Creating a program depending upon exercise specificity Progression to higher levels only after carefully evaluating the results of previously performed exercises.

Objectives of the Exercise Programme Pain Reduction Improve muscle strength & Endurance. Manage mechanical stresses on spine. Upgrade individual fitness levels to prevent reinjury. Provide stability to hyper mobile structures. Improve posture, mobility & flexibility

Advantages of exercising Improved capacity of bones, ligaments and muscles. Strengthen the neuro motor co ordination. Promote well being of the patient Central and peripheral relaxation by reducing the muscle tension Enhances Endorphin levels in the cerebro spinal fluid thus giving pain relief. Directly increase oxygen consumption in muscles. Improves nutrition around the discs and articular cartilage of small joints. Effects the psychogenic systems by negating symptoms of depression and anxiety Enhances overall stress bearing capacity.

The Exercise Regime Classification 1 Classification 2 1) Cardiovascular Regime 1) Flexion and Extension exercises 2) Floor or strength Regime 2)Rotational Exercises 3) Flexibility and stretching regime 3) Mobility Exercises 4) Core strengthening 4) Stretching exercises: General/ specific 5) Medicine ball regime 5) Self correction & maintenance exercises. 6) Stabilization exercises 6) Specific exercises: Isometric/isotonic/ isokinetic. 7) Aerobic Exercises During all exercises, one must avoid: touching the toes, bilateral SLR, arching the back in prone lying & hyperextension.

A. Cardio vascular Regime

1. Aerobic Exercise : Whole body stretch With both arms and both feet apart, the person is asked To bring legs together and palms at sides alternatively.

In a rhythmic manner, the person is asked to hold the calf muscle, With the opposite hip and knee at 90 degrees, the body must tilt slightly While looking straight up to the ceiling. This can be done alternatively and Should be ended in a relaxed stooping position.

Compiling the rotation of upper spine and flexion to touch the toes, Along with breathing enhances oxygen capacity of soft tissues.

Stretching the oblique muscles by flexing one hip & knee along with arm abduction. This improves room for effective respiration and more cardiovascular activity

Hydrotherapy – Exercising in water, improves muscle activity and Overall oxygen consumption by the body. The water can be used both as resistive or assistive effects.

2. Prone Floating Prone Floating: Extremely beneficial for relaxing the back muscles. This technique also serves as starting position for back extension exercises.

B. Stretching exercises

1. Active Hamstring stretch Technique: Pull thigh towards your chest by grasping the thigh under your knee. Extend the knee slowly, hold till ten counts and relax. Practice 10 repetitions.

2. Gluteal Maximus stretch Grasp underside of thigh, raise opposite leg and bring it across the other leg, pull your thigh towards the chest until a stretch is felt on the opposite buttock.

3. Hip Flexor stretch Kneel on one leg, other leg bent at 90 degrees with foot placed on the floor. With drawing the abs in, contract the buttock of the kneeling thigh. From the leg which is off floor, slightly lean forward from the knee and hold for 3-5 seconds. The stretch is felt on the hip flexors on the side of kneeling thigh.

4. Back Flexion Grasp both knees from below the thighs and bring them towards the chest. Make sure to not lift your body up from the bed, hold till 10 counts and release.

5. Basic Draw-In With knees bent & feet on floor, tighten the abdominal muscles to attain neutral spine. Brace the abdominal muscles by visualizing the belly button towards floor. Now, the abdomen ‘draws in’ and pucks lower. Hold this for 5-10 counts and do ten reps.

6. Hip Flexor and Quads stretch With person in side lying, he is asked to stabilize the head by placing his palm. A self stretch can be performed flexing the knee and extending the hip at the same Time so that the heel touches the back of the hip.

7. Quads stretch in half kneeling and Oblique muscle stretch Hip flexor of left side And quadriceps of the Right side can be stretched. b. With both knees bent together at one side, the person looks towards the opposite side to stretch the oblique muscles and hip abductors.

The Pectorals, oblique muscles and the Erector spinae can be stretched well in this position. The person must be able to support the upper body on one palm and Both knees.

Sliding the heel in bed and straight leg raising with dorsiflexion is effective for stretching the Achilles tendon. Sliding down the upper body against the wall to perform mini squats initiates quadriceps activation. While, raising the heels and toes facing the wall is beneficial For entire lower limb stretch.

Yoga Postures for upper and lower back stretching

Exercise Warrior Camel’s Pose Fish Variations

Wheel Pose King Dancer Pose Row Pose

Other stretching techniques

C. Floor Exercises

1. Isometric Supine Bridge In supine lying, with knees bent, the patient is asked to lift the buttocks and low back off the floor. Patient is instructed to tighten the abs and most importantly- breathe.

2. Side bridge Start in side lying position. One leg is fixed on top of the other and body is lifted off the floor. Bottom of the foot and side arm however is on the floor. Drawing the abs in, will help retain this position. Hold till ten counts and relax.

3. Back Extension Start in prone lying with chest touching the ground. The patient is instructed to first raise the chest till the level of elbows followed by both palms. The hips must not lift and the exercise must be done only till the comfort level of patient.

4. Prone Bridge In prone lying, both the elbows are bent and are in contact with each other. The arms should be directly under the shoulders and legs in extension completely, with only toes touching the floor. This bridge is then performed with abs tightened for about 20 seconds and relaxed.

5. Modified Prone Cobra Slight trunk elevation off the floor while hips and abdomen stay in contact with the floor. This exercise is for the lower back muscles only and efficacy is further enhanced when patient actively tightens the gluteal muscles and hold till 5-10 counts.

6. Quadruped – Bird Dog Position Performed by combining arm extension and opposite leg extension. And vice-versa. The abdominals are held tight and the set is repeated till ten counts for ten times.

7. Cat and camel exercise This exercise is a motion and not a stretch. Performed by alternately rounding the back (like a frightened cat) and lowering the spine slightly past neutral (like a camel). Be sure to not push at the end range of any motion. Repeat the set for ten counts.

8. Partial Abdominal Curls

9. Prone bridging with narrow base of support and feet supported on chair

10. Hip adductors and abductor strengthening The person is asked to lie down on his side with feet close. Both knees can be pressed together for adductor contraction while one hip can be raised for abductor strengthening with without feet losing contact with each other.

11. Hamstring strengthening Digging heel in the bed for knee flexor strengthening

12. Modified single leg Bridging

13. Legs up the wall pose

14. Trunk Rolling Correct Trunk Rolling Incorrect Trunk Rolling

15. Straight Leg Raising Straight leg raising is performed starting with flexion and extension of the foot. This is followed by moving the foot in circular and square motion.

16. Abdominal Curls Partial abdominal curls are done using a foam roller under buttocks Arms can be held forwards and shall later be kept behind the head for progression.

D. Medicine Ball Chops And Rotations

1. Overhead chops

2. Full twists and trunk rotations Entire body rotates as one unit.

3. Medicine ball – Diagonal Chops Perform Chops across the body

4. Medicine Ball- Full Circles A tight core is maintained while the body feels fluid and relaxed.

5. Hip and abdominal stability With back supported on the medicine ball, patient is asked to grasp another smaller ball between both hands and move the arms overhead and down.

6. Ball Press. The person is asked to hold the upper body by extending the arms and press down on the ball both buttocks together or alternatively.

7. Side Tilts The person tilts sideways on the ball alternatively to the left and right

8. Side Bending The person raises one arm overhead and tries to bend to the opposite side. The other hand is always supported on the ball.

9.Ball Rotations With lower body stabilized on the ball, the person is asked to join forearms together and rotate the upper body at fixed pelvis.

E. Core Strengthening and Stability Exercises Using a Physio ball.

1. Physio ball wall squat Starting position: With physio ball centered at the back, feet apart and in front of the patient’s body, elbows bent at 90 degrees and shoulders retracted. Patient is then asked to descend with abs drawn in & arms extended forwards. Arms are fully extended and thighs are parallel to the floor. The patient is then asked to ascend by pushing off from heels and exhaling normally.

2. Seated Draw-In on Physio Ball. Patient is instructed to tighten the abdominals, or in simple words, to make yourself as thin and tall as possible. Brace the abdominals for 5 counts while maintaining the spine in neutral and keeping the head and chin up.

3. Alternating Arm and Leg March Patient is instructed to brace the abdominal muscles to stabilize the trunk on the ball. The right arm is raised along with lifting the left thigh off floor and vice versa. Perform one set of ten repetitions. Most importantly – Remind patient to breathe normal.

4. Crunches On The Ball Starting Position: Ball centered at the back, abdominals braced, patient is asked to crunch partially to just contract the abs. This can be done in three directions: Forwards, Right and left. Perform 10 repetitions of each set.

5. Back Bridge on the Wall Patient is instructed to raise the hips so that back is in line with the thighs. This is followed by contraction of hamstrings and gluts. The efficacy of exercise can be further increased by pressing a volley ball between thighs. Hold position for 20-30 seconds and repeat set 5 times.

6. Prone Bridge on the Physio Ball. The patient is asked to place elbows on the ball and be up on the toes. The abdominals are braced to stabilize the spine. The position is held for 20-30 seconds and repeated 3-5 times.

7. Prone Flies Patient is instructed to extend the arms out in front with thumbs up and raise the arms up to shoulder height. Hold the position for 3-5 counts repeat the set ten times.

8. Prone Diagonals Patient is instructed to raise one leg and one arm. Initiate upper body lift from the shoulder blades. Perform the set alternately. Hold the position for 5 counts and Repeat ten sets each.

9. Isometrics With upper back fixed on the ball, the person is asked to hold dumb bell and tighten the abdominals and back muscles alternately.

10. Prone bridging with elbow support

11. Cycling with ball Performing cycling movement while alternately moving the arm overhead and to touch the knees.

12. Modified Supine Bridging Performed in three steps of progression where the base of support is gradually reduced and focus is on maximum back extension.

F. Stabilizing Exercises

A. Hip Extension With both hands on the back of the chair, shift weight on to the right foot and lift the left foot off floor. This can be done alternately for both legs, held for 10 counts For ten times each.

B. Modified Hip Extension Start with hands and knees in table top position, make sure the hands are below shoulders and knees are below hips. Brace the abdominals and lift your right leg off floor and vice versa.

C. Chair Pose –Targets back and Hamstrings Beginners may start with low intensity using a chair. Arms are raised until parallel to floor and patient is asked to squat slightly. With keeping the weight on the heels, the hips are pushed backwards. This position is held for 5 seconds keeping in mind that the knees do not extend over the toes of patient.

D. Isolated back extension – Targets Back and abdomen. To begin with the low intensity, one can lie face down on a mat with forehead resting on back of the hands. The chest, head and shoulders are lifted slowly off the floor without arching the back. This position is held for 5 seconds. As progression, this exercise can be performed with arms overhead and feet off the floor.

E. Child’s Pose : Targets abdomen, hips, buttocks and back. Level 1 : Sit on the chair with feet and palms both supported on the floor after leaning to relax.

Child’s pose : Level 2 Instruction to patient: On your knees sit on the floor in front of a chair. Keeping your arms straight, reach forward and place your hands in the seat of the chair. Tuck your chin in toward your chest and press your buttocks back toward the heels of your feet.

Child’s pose: Level 3 Instruction to patient: Sit on the floor on your knees. Keeping your arms straight, reach forward and place your hands on the floor. Rest your forehead on the floor and press your buttocks toward the heels of your feet.

Other stabilizing exercises a. Prone bridging with weight lifting: Improves spinal stability and abdominal strength

b. Full abdominal curls: The person stabilizes anterior pelvis and calves , and bends down completely to achieve lumbar flexion

c. Assisted squatting: The person squats with toes supported and heels off the floor. Holding the back of a chair is essential to add more stability.

d. Bridging: Side, Prone & Supine. Raising one arm off the floor and narrowing the base improves back extensor and abdominal tone.

e. Back flexion and extension using Dumb bells and Thera Bands(Resistance bands)

f. Spine extension in half kneeling: The person is asked to hold an erect position with knees flexed on the floor. With both palms behind the head, he is asked to lunge forwards to achieve maximum spine extension (and not hyperextension).