This document discusses various exercises and techniques for rehabilitation of chronic lower back pain (CLBP). It finds that core stability exercises are more effective than stretching alone in improving tonic core muscle strength and endurance for CLBP. Several specific exercises are described to target the transverse abdominis, multifidus, diaphragm and pelvic floor muscles. Stretching techniques for the hamstrings, quadriceps and other muscle groups are also outlined. The document further discusses techniques for addressing sacroiliac joint dysfunction issues like upslips and downslips.

2.  It is discovered that core stability exercise promotes improvement in tonic core
muscle strength and endurance whereas muscular stretching does not in CLBP
rehabilitation.1
 The core also known as lumbo-pelvic-hip complex is attached to local (postural,
tonic) muscles which are responsible for providing segmental stability and directly
controlling of the lumbar segments during movement.
 Weakness and/or tightness of these groups of muscles will cause many disorganized
movements that leads to lower back injury.1

3.  This approach will offer a more biomechanical efficient for the entire kinetic chain of
the lumbo-pelvic-hip complex thus allowing the body to decelerate gravity, ground
reaction forces and momentum at the right joint, in the right plane and at the right
time.2
 Increased stability of the trunk will enable the individual to maintain the spine and
pelvis in the most comfortable & acceptable mechanical position that control the
forces of repetitive micro trauma and protect the structures of the back from further
damage.

4.  ADIM(Abdominal drwaing in manuever)
 side-bridge
 quadruped exercises can be used.2
 For the ADIM, 3 sets of 10 contractions, with a 10 second hold and 15 second rest,
can be used. (Figure 1).

6.  For the side-bridge exercise, the patient will start by lying on their right side, with the
weight-bearing elbow flexed and both knees flexed.2
 The position will be held for 10 seconds, with a 15-second rest. 3 sets of ten
contractions can be performed. (Figure 2).

8.  Lastly, for the quadruped exercise, the patient will adopt quadruped position.
Keeping a flat back, the patient will perform the ADIM, holding the contraction for 10
seconds with 15 seconds rest between contractions.2 (Figure 3).

10. 1. In a supine position, the subject placed a ball below the neck, bent the knees, and
crossed and bent 90° the arms so that the crossed arms came to the eye level.
While breathing out, the subject slowly raised each lower limb in turn. The subject
performed the motion of bending the hip joint and the knee joint 90° five times, for
10 seconds each time.3

11. 2. In a supine position, the subject placed a ball below the pelvis, bent the knees, and
crossed and bent 90° the arms so that the crossed arms came to the eye level. The
subject performed the motion of pressing the ball below the pelvis slowly five times,
for 10 seconds each time.3

12. 3. In a crawling position, the subject placed a ball below one knee and kept the toes away
from contact with the floor. The subject balanced first to stabilize the posture and
slowly raised the other lower limb. This exercise was performed in turn for the two
lower limbs 10 times, for 10 seconds each time.3

13. 4. After assuming a prone position, the subject placed a ball in front of the pelvis and
raised both lower limbs. As if kicking, the subjects repeatedly raised and lowered the
two lower limbs alternately. The subject performed this exercise 10 times, for five sets,
taking a rest of at least 15 seconds between each set.3

14.  Stretching is widely used in physical therapy which helps in alleviating CLBP by
progressively stretching the muscle groups which are assumed to be too short,
especially the lumbar spinal muscle and the hip flexors and extensor.6,7
Stretching

15. Self stretching techniques to increase lumbar flexion5,6
Hamstrings
stretch
Lumbar erector spinae muscle
and tissue posterior to the spine

16.  Jack-knife stretch is a useful active static stretching technique to efficiently increase
flexibility of tight hamstrings. One set consisted of 5 repetitions, each held for 5 s.
(4weeks).6
Jack-knife stretch

17.  Active stretching to the hamstrings, quadriceps, and triceps surae muscle reduce
muscle tightness in paediatric patients with lumbar spondylolysis.One set of 5
repetition with 10seconds hold.7
Quadriceps stretch Triceps slae muscle

18. Self stretching techniques to increase lumbar extension:5
Self stretching of the soft tissue anterior to the lumbar
spine and hip joint with the patient (A) prone and (B)
standing.

19. Self-slump stretching home exercise program.
Patient Position- long sitting, feet against a wall to maintain neutral dorsiflexion
angle, trunk flexed to enhance dural elongation, active neck flexion with
overpressure from their hands until the onset of symptoms. Five repetitions of 30-
second holds.8
Self-slump stretching

20. Self stretch techniques to increase lateral flexibility of
the spine
Patient with a right thoracic left lumbar curve. Patient actively stretches
thoracic curve by reaching upward on side of concavity and downward on side of
convexity.

21. Self stretch techniques to increase lateral flexibility of
the spine
Heel-sitting position with patient
reaching the arms overhead and
then walk the hands toward the
convex side.
Side-lying with a rolled towel at
the apex of the convexity

22. Self stretching techniques to increase thoracic
extension:
A) Touchdown position
B) With the shouldes abducted and laterally rotated.
C) Adducting the scapula and
extending the thoracic spine
against the back of the chair.

23. Positional Traction: Lumbar spine
 Patient position:
 Side lying, with the side to be stretched uppermost.
 A rolled blanket or thick towel is placed under the spine at a level where the
traction force is desired.
Side bending over a 6 to 8 inch roll causes longitudinal
traction to the segments on the upward side.

24.  Rotation is added to isolate a distraction force to the desired level.
 Flex the patient's upper most thigh, again palpating the spinous processes until
flexion of the lower portion of the spine occurs at the desired level. The segment at
which two opposing forces meet now has maximum positional distraction forces.
Side bending with rotation adds a distraction force to the facets on the
upward side.

25. Self Traction: Cervical spine
 Patient Position:
 Siting or lying down.
 Have the patient place his or he hands behind the neck with the fingers
interlocking.
 The patient then gives a lifting motion to the head. The head and spine
maybe placed in flexion, extension, side bending or rotation for more
isolated effects. He or she may apply the traction intermittently or in a
sustaied manner.
 Recommendations varies from few min to 40 minutes. 15-30seconds hold
with 5-10 seconds rest.
 Saunders et al advised 8-10min of spinal traction in disc protrusion
whereas Hickling et al advised 20-40min of spinal traction in disc
protrusion.19,20

26. Self Traction: Cervical spine

27.  Shih-Lin Hsu et al in their study found that exercises for the transverse abdominis,
multifidus, diaphragm, and pelvic floor muscles helps to improve core strength.
Core strength training
1. Transverse abdominis and multifidus muscle,
Hand-knee bird dog exercise with draw-in can be performed for 30 s ×10 sets.

28. 2. Diaphragm muscle
Abdominal inspiratory exercises with a 3-kg weight resting on the abdomen was
performed for 10 min.

29. 3. Pelvic floor muscles
Exercise requiring maximal contraction of
the perineal muscles in a sitting position
against a towel between the thighs was
performed 15 times × 2 sets.

30. A series of studies showed that 3 forms of exercise produced stabilizing patterns,
specifically for flexion dominant challenges using a form of the curl-up, frontal
plane challenges using the side-bridge, and extensor dominant challenges using
the birddog.10,11
Specific transverse abdominis and multifidus training are not as effective as
multimuscle therapeutic exercises. More recently, Suni et al showed that the
position of the spine (neutral in this case) when performing exercise resulted in
better outcome.12

31.  Fritz et al showed that those patients with stiff backs did better with mobilizing
approaches, whereas those with unstable backs did better with stabilization
exercise.13
Hicks et al16 have shown that testing for shear instability (using the test described
by Magee17) was a good predictor of those who would do well with stabilization
exercise approaches.14

34.  Upslip and Downslip Ilium are patterns of sacroiliac joint (SIJ) dysfunction
(SIJD) that are commonly described in the literature.15
 An ‘upslip’:
1. may co-exist with a ‘rotational malalignment’ and/or an ‘outflare/inflare’
2. occurs considerably less often than ‘rotational malalignment’.
 Common signs for left Upslip:16
1. Functionally shorter leg length on the left
2. Left Iliac crest superior vs. right
3. Left PSIS superior vs. right
Iliac Crest Height left superior to right

36.  A unilateral ‘downslip’ occurs rarely and the diagnosis is frequently delayed or
missed altogether.16
 Typically, there is a history of excessive traction on an extremity.
 In posterior innominate rotation, the anterior superior iliac spine is carried
superior and posterior, the posterior superior iliac spine is carried anterior and
inferior, and the ischial tuberosity is carried anterior and inferior

37. Common signs for right anterior Innominate:
Functionally longer leg length on the right
Anteriorly rotated ilium (Right ASIS appears
inferior)
Right PSIS superior vs. left..
ASIS Height Right inferior to left

38. Treatment of Upslip:
1. trigger point release to the quadratus
lumborum
2. Muscle energy technique to the
Quadrautus Lumborum
3. Isolated strengthening of right
Quadratus Lumborum via right hip hike
(approximation).
Treatment of anterior innominate:
1. trigger point release to the hip flexors
2. Muscle energy technique to the
Quadrautus Lumborum
3. Isolated strengthening of the Right
Gluteus Max via single leg floor bridge.
Common trigger point (QL)
Trigger points for TFL and Rectus
Femoris

39. 1. Self myofascial release to quadratus lumborum: Once tender spot is located
lean back in to the ball with moderate pressure and hold for 30-60 seconds.
Myofascial release tools such as a Thera-Cane or Backnobber can be used to
release the QL.

40. 2. Static self stretching of the quadratus lumborum.

41. 3. Isolated strengthening of right Quadratus Lumborum via right hip hike
(approximation): Stand on a 6-12” box or step, with the right leg hanging off
and weight shifted over the left leg. Slowly pull up or hike the right leg. The
right iliac crest should move toward the right 12th rib. Hold the up position
for 2 seconds and slowly return to the starting position. Repeat for 10-15
repetitions. For increased intensity, add a cuff weight to the ankle.

42. 1. Self Myofascial Release to the right Rectus Femoris and right TFL via foam
roll:
Rectus femoris : lie flat on the foam roll, the roll should be perpendicular
to the front of the thigh. Begin at the hip and slowly roll toward the knee. Hold
the tender spot for 30-60 seconds.
Foam Roll Rectus Femoris

43. TFL :lie down on the foam roll and rotate to approximately 45 degrees to
the side, so that the TFL is on the foam roll (near the area of the front
pocket). Once the tender spot is found hold pressure on the spot for 30-60
seconds.
Foam Roll TFL

44. 2. Static self stretching of the rectus femoris and TFL.
Rectus femoris stretch Tensor fascia lata stretch

45. 3. Isolated strengthening of the Right Gluteus Max via single leg floor bridge:
single leg floor bridge

46. A) MET INFLARE TECHNIQUE B) MET OUTFLARE TECHNIQUE

48. 1. Ebby Waqqash, Rahmat Adnan, Sarina Md Yusof, Shariman Ismadi Ismail. fficacy of
core stability exercise and muscular stretching on chronic lower back pain. Proceedings
of the International Colloquium on Sports Science, Exercise, Engineering and
Technology 2014 (ICoSSEET 2014).
2. Noelle M. Selkow, , Molly R. Eck, Stephen Rivas. TRANSVERSUS ABDOMINIS
ACTIVATION AND TIMING IMPROVES FOLLOWING CORE STABILITY
TRAINING: A RANDOMIZED TRIAL. IJSPT. The International Journal of Sports
Physical Therapy | Volume 12, Number 7 | December 2017 | Page 1048-56. DOI:
10.16603/ijspt20171048.
3. SinHo Chung, JuSang Lee, JangSoon Yoon. Effects of Stabilization Exercise Using a
Ball on Mutifidus Cross-Sectional Area in Patients with Chronic Low Back Pain.
Journal of Sports Science and Medicine (2013) 12, 533-541.
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52. THANKYOU
EVERYONE!