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

2. 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.

3. 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

4. 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.

5. 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.

6. A. Cardio vascular Regime

7. 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.

8. 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.

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

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

11. 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.

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

13. B. Stretching exercises

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. Yoga Postures for upper and lower back stretching

24. Exercise Warrior
Camel’s Pose
Fish Variations

25. Wheel Pose
King Dancer Pose
Row Pose

26. Other stretching techniques

27. C. Floor Exercises

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 8. Partial Abdominal Curls

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

37. 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.

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

39. 12. Modified single leg Bridging

40. 13. Legs up the wall pose

41. 14. Trunk Rolling
Correct Trunk Rolling
Incorrect Trunk Rolling

42. 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.

43. 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.

44. D. Medicine Ball Chops And Rotations

45. 1. Overhead chops

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

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

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

49. 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.

50. 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.

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

52. 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.

53. 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.

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

55. 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.

56. 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.

57. 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.

58. 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.

59. 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 seconds and repeat set 5 times.

60. 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 seconds and repeated 3-5 times.

61. 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.

62. 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.

63. 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.

64. 10. Prone bridging with elbow support

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

66. 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.

67. F. Stabilizing Exercises

68. 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.

69. 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.

70. 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.

71. 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.

72. 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.

73. 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.

74. 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.

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

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

77. 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.

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

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

80. 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).