The Spine: Exercise Interventions Chapter 16

Basic concepts of spinal management with exercise

Fundamental Interventions Definition: Exercises or skills that all patients with spinal impairments should learn….at the time of examination and initial intervention Kinesthetic training Stabilization training Functional training of basic body mechanics Box 16.1 contains Fundamental Exercise Interventions for Spinal Rehabilitation.

Patient Education Active Participation Limitations at Each Stage of Healing Safe Self-Management Instruction Prevention

General Exercise Guidelines Kinesthetic Awareness Mobility/Flexibility Muscle Performance Cardiopulmonary Endurance Functional Activities Table 16.1 outlines Spinal Rehabilitation. Table 16.2 summarizes Intervention for Each Phase of Rehabilitation.

KINESTHETIC AWARENESS Goal: To develop proprioception of spinal positioning, safe movement, and postural control.

Elements of Kinesthetic Training: Fundamental Techniques Position of Symptom Relief (position of bias) Cervical spine Lumbar spine Effects of Movement on the Spine Blending of Kinesthetic Training, Stabilization Exercises, and Fundamental Body Mechanics

Progression to Active and Habitual Control of Posture Use of Reinforcement Verbal, visual, tactile Identify Any Need for Postural Support Integrate Awareness of Postural Control Body mechanics Functional activities

Mobility/flexibility Goal: To increase ROM of specific structures that affect alignment and mobility in the neck and trunk.

Cervical and Upper Thoracic Region: Stretching Techniques Techniques to Increase Thoracic Extension Self-stretching Techniques to Increase Axial Extension (Cervical Retraction): Scalene Muscle Stretch Manual stretching

Cervical and Upper Thoracic Region: Stretching Techniques (cont'd) Techniques to Increase Upper Cervical Flexion: Short Suboccipital Muscle Stretch Manual stretching Self-stretching Traction as a Stretching Technique Manual traction: cervical spine Self-traction: cervical spine Figure 16.5 illustrates Manual Cervical Traction.

Cervical Joint Manipulation Techniques Grading I–V: Definitions Precautions Contraindications

Cervical Joint Manipulation Techniques (cont'd) Manipulation to Increase Cervical Flexion Manipulation to Increase Cervical Extension Manipulation to Increase Cervical Rotation Manipulation to Increase Cervical Rotation and Sidebending Manipulation to Increase Cervical Rotation and Sidebending-Alternate Technique

Muscle Energy Techniques to Increase Craniocervical Mobility To Increase Craniocervical Flexion To Increase Craniocervical Rotation Figure 16.11 illustrates Muscle Energy: Craniocervical Flexion. Figure 16.12 illustrates Muscle Energy: Craniocervical Rotation.

Mid and Lower Thoracic and Lumbar Regions: Stretching Techniques Techniques to Increase Lumbar Flexion Self-stretching Techniques to Increase Hip Muscle Flexibility Traction as a Stretching Technique Manual traction: lumbar spine Positional traction: lumbar spine Figures 16.13 and 16.14 illustrate self-stretching techniques to increase lumbar flexion.

Thoracic and Lumbar Joint Manipulation and HVT Techniques Manipulation to Increase Thoracic Spine Extension Manipulation to Increase Thoracic Spine Flexion Manipulation to Increase Thoracic Spine Rotation Pistol Thrust to Increase Thoracic Spine Mobility Cross-Arm Thrust to Increase Thoracic Spine Mobility Fall Thrust to Increase Thoracic Spine Mobility

Thoracic and Lumbar Joint Manipulation and HVT Techniques (cont'd) Rib Manipulation for Inspiratory Restriction Rib Manipulation for Expiratory Restriction Elevated First Rib Manipulation

Thoracic and Lumbar Joint Manipulation and HVT Techniques (cont'd) Manipulation to Increase Lumbar Spine Extension Manipulation to Increase Lumbar Spine Rotation Manipulation to Increase Lumbar Intervertebral Sidebending HVT Lumbar Roll to Increase Lumbar Rotation

Thoracic and Lumbar Joint Manipulation and HVT Techniques (cont'd) SI Joint Manipulation Technique to Increase Sacral Nutation (Flexion) SI Joint Manipulation Technique to Increase Sacral Counter-Nutation (Extension) HVT Posterior Rotation to Innominate

Muscle performance: stabilization, muscle endurance, and strength training Goals: To activate and develop neuromuscular control of deep segmental and global spinal stabilizing muscles to support the spine against external loading. To develop endurance and strength in the muscles of the axial skeleton for functional activities. To develop control of balance in stable and unstable situations.

Stabilization Training: Fundamental Techniques and Progressions Guidelines for Stabilization Training Stabilization Training: Fundamental Techniques and Progressions Box 16.2 summarizes the Guidelines for Stabilization Training: Principles and Progression. Shown here, Figure 16.37 illustrates how exercises to improve muscle performance, cardiopulmonary endurance, and functional activities are integrated over a background of activating the deep segmental and global multi-segmental spinal stabilizing musculature.

Deep Segmental Muscle Activation and Training Cervical Musculature Deep neck flexors Lower cervical and upper thoracic extensor Progression Stabilization Training: Fundamental Techniques and Progressions Box 16.3 summarizes Testing and Training Deep Segmental Muscle Activation in the Cervical Spine.

Deep Segmental Muscle Activation and Training (cont'd) Lumbar Musculature Drawing-in maneuver (abdominal hollowing exercise) for transverse abdominis activation Abdominal bracing Posterior pelvic tilt Multifidus activation and training Stabilization Training: Fundamental Techniques and Progressions Box 16.4 summarizes Testing and Training Deep Segmental Muscle Activation (Transversus Abdominis) in the Lumbar Spine.

Global Muscle Stabilization Exercises Stabilization Exercises for the Cervical Region Stabilization with progressive limb loading Variations and progressions in the stabilization program Integration of stabilization exercises and posture training Progression of isometric and dynamic strengthening in conjunction with functional activities Stabilization Training: Fundamental Techniques and Progressions Table 16.3 summarizes Cervical Stabilization with Progressive Limb Loading: Emphasis on Cervical Flexors. Table 16.4 summarizes Cervical Stabilization with Progressive Limb Loading: Emphasis on Cervical and Thoracic Extensors. Box 16.5 contains Instructions for use of Stabilizer for Stabilization Training with Leg Loading.

Global Muscle Stabilization Exercises (cont'd) Stabilization Exercises for the Lumbar Region Stabilization with progressive limb loading Variations and progressions in the stabilization program Quadratus lumborum: stabilization exercises Progression to dynamic exercises Stabilization Training: Fundamental Techniques and Progressions

Isometric and Dynamic Exercises Exercise for the Cervical Region Isometric exercises: self-resistance Isometric resistance activities Dynamic cervical flexion Manual resistance: cervical muscles Intermediate and advanced training Transitional stabilization for the cervical and upper thoracic regions Functional exercises

Isometric and Dynamic Exercises (cont'd) Exercise for the Thoracic and Lumbar Regions Alternating isometric contractions and rhythmic stabilization Dynamic strengthening: abdominal muscles Trunk flexion Trunk flexion (abdominals): sitting or standing

Isometric and Dynamic Exercises (cont'd) Exercise for the Thoracic and Lumbar Regions (cont’d) Dynamic strengthening: erector spinae and multifidus muscles Extension exercises in prone or quadriped position Extension exercises sitting or standing Trunk side bending (lateral abdominals, erector spinae, quadratus lumborum)

Cardiopulmonary Endurance Goal: To develop cardiopulmonary fitness for overall endurance and well-being. Box 16.6 summarizes Aerobic Conditioning Principles.

Common Aerobic Exercises and Effects on the Spine Cycling Walking and Running Stair Climbing Cross-Country Skiing and Ski Machines Swimming Upper Body Ergometers Step Aerobics and Aerobic Dancing “Latest Popular Craze”

Functional Activities Goal: To progress to independence safely.

Early Functional Training: Fundamental Techniques Goal: Progress to Independence Safely Rolling Supine to Sit/Sit to Lying Down Sit to Stand/Stand to Sit In and Out of a Car Walking

Preparation for Functional Activities: Basic Exercise Techniques Weight-Bearing Exercises Modified bridging exercises Push-ups with trunk stabilization Wall slides Partial lunges, partial squats, and steps Walking against resistance

Preparation for Functional Activities: Basic Exercise Techniques (cont'd) Transitional Stabilization Exercises Quadriped forward/backward shifting Squatting and reaching Shifting weight and turning

Body Mechanics and Environmental Adaptations Principles of Body Mechanics: Instruction and Training Lumbar spine position Spinal flexion Spinal extension Load position

Body Mechanics and Environmental Adaptations (cont'd) Home, work, and driving considerations Sleeping environment

Intermediate to Advanced Exercise Techniques for Functional Training Repetitive Lifting Repetitive Reaching Repetitive Pushing and Pulling Rotation or Turning Transitional Movements Transfer of Training

Education for Prevention Continual Throughout the Rehabilitation Process Relationships of Posture and Pain Home Exercise Program Flexibility Muscle endurance Strengthening Cardiopulmonary

Independent Learning Activities Critical Thinking and Discussion Laboratory Practice Case Studies