OA

©2008 OA • 33 Sewall Street • Portland, ME 04102 • (207) 828-2100

Spine Stabilization Protocol

The protocols provided by OA Centers for Orthopaedics are examples of those used by our physicians and may not be appropriate for every patient. You should use these only if your treating physician has reviewed the protocol and approves of its use for your recovery.

BACK PAIN IS ALL TOO COMMON AND CAN BE QUITE COMPLICATED. In fact, eighty percent of people will experience low back pain. Of these people, ninety percent will have recurrent pain. This information is intended to help answer some frequent questions and help you recover from, or lessen, your symptoms through exercise, body mechanics and proper posture.

THIS IS A GENERAL GUIDE FOR YOU AS THE PATIENT TO BETTER UNDERSTAND THE GUIDELINES AND EXERCISES USED TO PROGRESS BACK PAIN PATIENTS THROUGH THEIR REHABILITATION. Please keep in mind that these are guidelines and that exercises should be reviewed in detail by the therapy team that is working with you. Understand that you should progress at your own individual pace, attempting to make gains on a daily and weekly basis—to achieve progression in the protocol—with respect to your own individual recovery abilities.

YOU SHOULD BE EVALUATED AT REGULAR INTERVALS. Throughout the rehabilitation process your therapists should re-evaluate and discuss your progress with you and your referring physician regularly.

THE PRIMARY GOALS TO STRIVE FOR EARLY IN THE PROGRAM ARE:

  1. Recognize the role of the physical therapists working with you.
  2. Regain control of a normal, healthy, and safe posture to take stress off the spine.
  3. Improve your tolerance to exercise and higher level activities.
  4. Early recognition and treatment of any problems in your recovery—i.e., difficulty with working postures, trouble driving, or bad habits.
  5. Learn to understand your limitations and "respect the healing process".

MOST PATIENTS FIND SUCCESS IN THERAPY. This means that the length, intensity, and duration of symptoms will be much less severe. It is important for you to understand that your back pain may not disappear—rather, our intention is to help you learn how to lessen the symptoms so that you can resume normal activity and minimize the risk of re-injury in the process. You should note improvements over time and through appropriate activity (i.e., correct posture, strengthening, stretching, and walking). Gradually this will allow optimal healing and fewer symptoms. Generally, prolonged rest and inactivity will weaken supporting structures. This is important for you to remember as you experience occasional difficulties recovering all of your strength. It is essential that you rest your back enough to let it recover from stress, however that rest needs to be balanced with the exercises to support it.

IT IS IMPORTANT FOR YOU TO RECOGNIZE THE ROLE OF THE PHYSICAL THERAPIST IN THE RECOVERY PROCESS. The PT will act more as a coach and facilitator--giving direction and advice. They will instruct you in appropriate posture, body mechanics, strengthening exercises, and specifics on how aggressively to progress with exercises, walking, and returning to work in a timely manner. Pool exercises are also often used to minimize stress on the spine. The therapist will check your progress regularly, and will determine your success with the program through functional tests and by measuring improved tolerance to repeated exercise.

Recovery From Back Pain

HOW WILL P.T. HELP? Low back pain can originate from many sources including the vertebrae, discs, facet joints, pelvis, sacrum, muscles, nerves, ligaments, and other connective tissues. Proper posture can alleviate excessive stress on the above structures. This back program will strive for a balance between strength and flexibility which will encourage proper posture. Your physical therapist will also teach you how to use your body to reduce excessive stress to your back and decrease your chance of re-injuring yourself.

WHY IS IMPROVING FLEXIBILITY AND STRENGTH IMPORTANT? Low back pain can originate from many sources including the vertebrae, discs, facet joints, pelvis, sacrum, muscles, nerves, ligaments, and other connective tissues. Proper posture can alleviate excessive stress on the above structures. This back program will strive for a balance between strength and flexibility which will encourage proper posture. Your physical therapist will also teach you how to use your body to reduce excessive stress to your back and decrease your chance of re-injuring yourself.

WHY IS IMPROVING FLEXIBILITY AND STRENGTH IMPORTANT?

  1. To remove abnormal stress from the spine and facilitate proper spinal motion.
  2. To allow your legs to work more efficiently. The muscles of the thigh attach on various parts of the pelvis which moves in combination with the low back. If some of these muscles are tight or shortened, they will pull on the pelvis, affecting the function of the lower back.
  3. Both your back and abdominal muscles work as a team to hold your back stable.
  4. Strong legs are required to keep the pelvis and back stable and should do more of the lifting than your back.

WHAT IS PROPER POSTURE? Posture is the position in which you hold your body. Posture will play a large role in the health of your back. Here are some general guidelines.

Lying

Standing

Sitting

• On your back with pillow(s) under the knees, using one pillow under the head and neck
• Sidelying with knees bent, using one pillow between knees, and one under the head
• feet flat on the floor (no high heels) knees slightly bent, not locked hips aligned over ankles shoulders aligned over hips chin tucked, ears aligned over shoulders keep abdominal muscles tight • feet supported by floor or stool
• hips and knees bent, hips = or higher than knees
• support curve of back with back of chair or cushion
• shoulders over hips
• head over shoulders, chin tucked

HOW DO I KEEP PROPER POSTURE AND RETURN TO MY REGULAR ACTIVITIES? Body mechanics is a term used to describe how you use your body. Most of us move around without thinking much about how our body is moving - until we have pain! So you probably have learned "poor" body mechanics that are now habits. These habits can cause a lot of undue stress and pain. Did you realize the average person bends 3,000 to 5,000 times a day? Here are some general guidelines you can adapt to many situations.

  1. Plan ahead.
  2. Keep spine neutral with abdominal bracing.
  3. Squat or use a step stool to adjust to the height of the task. The easiest height to lift from is chest to waist height.
  4. Keep a good base of support / wide stance.
  5. Keep the load as close to you as possible.
  6. Use your arms or legs to lift, push, or pull.
  7. Avoid twisting your back. Your hips and shoulders should be pointing in the same direction in which you are working.
  8. Get help for heavy or awkward loads.

Abdominal Exercises:

  1. Find pelvic neutral: (Hooklying=lay on back with knees bent). This is the position which is not at the extreme arch or flattened position, and should be the least painful position.
    Control this by tilting your pelvis and use your abdominals and low back muscles to hold it there.
    Maintain this regularly throughout the day, and become accustomed to finding it and holding it as you lie down, sit, stand, and then bend and lift.

  2. Abdominal Crunches: (Hooklying position). Maintain neutral and contract the abdomen as hard as possible while lifting the head and shoulders up from the table slightly. Hold this position for 3-5 seconds, then return to the starting position slowly and without losing neutral. You may alter the arm position by placing them across your chest or behind your head, using caution to avoid pulling on your neck.

    Repeat until you are unable to maintain the neutral position any longer, or your abs are fatigued.

    Start this week with______ repetitions (reps)/time.

    The goal is______

  3. Single Leg Lifts: (Hooklying position). Maintain neutral and contract your abs.
    A. Slowly lift one leg up (with your knee bent) so that you hip is bent to about 90 degrees. Slowly lower to the starting position and repeat the movement.
    B. Further advance this by straightening one leg without resting it on the floor, then return to the starting position with knees bent. Alternate with the other leg.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs in ankle weights

  4. 90/90 Hold: (Supine). Maintain neutral, contract abs, lift one or both legs up to have 90 degree angles at the hip and knees. Do not allow your back to arch during this lift. Hold this position and time yourself.

    Start this week with _____second holds.

    The goal is 3 minutes without losing neutral or having symptoms. If you are not ready for this yet, hold one leg up while maintaining the neutral position for increasing amounts of time, until you gradually strengthen enough to hold both legs up without pain.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs in ankle weights

  5. Heel Taps: (Hooklying position). Maintain neutral and contract your abs. Lift both legs to the 90/90 position. Slowly lower one leg down (with your knee bent 90 degrees) to tap your heel against the surface. Raise back up to the starting position and repeat.

    Make this more difficult be alternating taps with the other leg.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs in ankle weights

  6. Bicycle: (Supine). Maintain neutral position, raise both legs to 90/90 position, and "pedal" by making small circles with your feet. Try not to bend your hips greater than 90 degrees.

    Begin with _____ minutes of continuous movement without losing neutral.

    As you improve, attempt larger circles and try to reach a goal of 3 minutes of continuous circles.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs in ankle weights

  7. Dying bug: (Supine). Maintain neutral. Assume the 90/90 position. Straighten one leg and raise the opposite arm overhead. Slowly return to the starting position and alternate sides. Do not allow the arms or legs to rest on the surface. Progress this to raising both arms and legs on at the same time.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs in ankle/wrist weights

Bridging Exercises:

  1. Classic Bridge: Lie on back with knees bent, feet flat on floor. Lift your hips as high as you can without losing the neutral position. Hold this for 5 seconds then slowly return to starting position.

    Start this week with _____ reps/time

    The goal is ______

    Progress this exercise by holding the bridge position as long as you can instead of doing reps up and down.

  2. Bridging March: Lift into bridge position. Keeping your hips raised and level, slowly lift one foot approximately 6 inches, then return foot to floor. Then lift opposite foot slowly as you begin "marching". Make sure hips/pelvis remain level. Progress this exercise by adding ankle weights.

    Start this week with _____ reps/time

    The goal is ______

    Add _____ lb. ankle weights

  3. Bridging Leg Extensions: Lift into bridge position and hold. Slowly bend one leg up toward your chest, then straighten it fully. Return that leg to the starting position then alternate with the other side. Keep hips/pelvis level while you maintain the bridge at all times. Progress by adding ankle weights.

    Start this week with _____ reps/time on each leg

    The goal is ______

    Add _____ lb. ankle weights

  4. Single Leg Bridges: Lie on back with one leg bent and the other out straight. Keep hips/pelvis level as you lift and lower your hips using the bent leg. Do not allow the straight leg to rest on the floor. Progress by adding ankle weights.

    Start this week with _____ reps/time on each leg

    The goal is ______

    Add _____ lb. ankle weight

Prone Back Exercises:

  1. Prone pelvic neutral position: Lay on your stomach and rock the pelvis to find the neutral position that is most comfortable. Learn to contract the spine and abdominal muscles to maintain this position. As with the supine position, think of bracing yourself, while maintaining the position that is most pain free. Repeat these contractions to master the position before progressing to other exercises.

  2. Prone single arm lifts: find neutral and maintain. Lift one arm up from the surface of the table. Keep your arm straight and only raise it as far as you can without arching your back (usually 3-6 inches is tolerable). Repeat single arm lift. Progress to alternating arm lifts.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs in wrist weights

  3. Prone single leg lifts: find neutral and maintain. Lift one leg up from the surface of the table. Keep your leg straight and only raise it as far as you can without arching your back (usually 3-6 inches is tolerable). Repeat single leg lift. Progress to alternating leg lifts.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs in ankle weights

  4. Prone opposite arm and leg lift: Maintain neutral. Lift one leg and the opposite arm 3-6 inches from the surface. Repeat on the same side, then on the other side. Start by repeating on the same side, then progress to alternating from side to side. Gradually increase the intensity by adding wrist and/or ankle weights as you get stronger.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in wrist/ankle weights

  5. Prone Superman: Maintain neutral. Lift both arms and both legs 3-6 inches from the surface. Be sure not to lift so high that your back arches. Repeat slowly. Gradually increase the intensity by adding wrist and/or ankle weights as you get stronger.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in wrist/ankle weights

  6. Prone Flutter-kick with Alternate Arm Lifts: Maintain neutral. Assume superman position and alternately "flutter kick" with arms and legs. Repeat slowly. Gradually increase the intensity by adding wrist and/or ankle weights as you get stronger.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in wrist/ankle weights

  7. Sidelying Bridges: Lie on side, support yourself on one elbow and stacked ankles. Lift midsection from the surface of the table. Maintain neutral to hold this position as long as possible, until you begin to lose neutral or note discomfort. Repeat this on the other side.

    Start this week with _____ reps/time

    The goal is______

Quadruped Back Exercises

  1. Quadruped pelvic neutral position: Position yourself on hands and knees and rock the pelvis to find the neutral position that is most comfortable. Learn to contract the spine and abdominal muscles to maintain this position. Repeat these contractions to master the position and build strength before progressing to other exercises.

  2. Quadruped single arm lifts: Find neutral and maintain. Lift one arm up from the surface of the table. Keep your arm straight and only raise it to shoulder level in front of you, without losing control of neutral and arching your back. Repeat single arm lift and progress to alternating arm lifts.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in wrist weights

  3. Quadruped single leg lifts: Find neutral and maintain. Lift one leg up from the surface of the table. Keep your leg straight and only raise it to hip level behind you, without losing control of neutral and arching your back. Repeat single leg lift and progress to alternating leg lifts.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in ankle weights

  4. Quadruped opposite arm and leg lift: Find neutral and maintain. Lift one arm and the opposite leg up from the surface of the table. Straighten your arm and leg, raising them only to shoulder/back level. Maintain the neutral position and do not arch your back. Repeat on one side and progress to alternating from side to side.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in wrist/ankle weights

Seated Exercises

  1. Seated neutral position: Maintain neutral. Correct your seated position to find a functional, neutral posture to maintain when seated (i.e., with work and driving). Practice this throughout the day as often as possible by holding it as long as you can tolerate. Realize that it is sometimes difficult to hold this for very long times, and a major accomplishment will be to improve trunk strength in this position to improve tolerance to prolonged driving, working on computers, etc. Alternate positions by sitting with back against chair as well as sitting on the edge with no contact.

  2. Seated abdominal contractions: Maintain seated neutral position. Learn to contract abdominals in an effort to "brace" your trunk to give the spine support. Learn this through repeated contractions throughout the day, and gradually eliminate exercise #1 as you become stronger and are better able to perform this exercise to provide support in prolonged seated positions.

  3. Seated abdominal side crunches: Maintain neutral. Perform lateral abdominal crunch by squeezing the side abdominal muscles. Think of pulling your ribs toward your hip, performing a small but very controlled motion. Add Theraband for resistance by attaching it to the wall and pulling the resistance across your chest, as instructed by your therapist. Move further from the wall to increase the resistance. Also add resistance by holding onto hand weights at your sides as you bend laterally.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in hand weights

  4. Seated single leg lifts: Maintain seated neutral position. Learn to contract the abdominals in an effort to "brace" your trunk to give the spine support. Slowly and carefully lift one leg to raise foot 4-6 inches from the floor. Repeat on the same leg, then repeat on the opposite leg.

    Progress to alternating leg lifts as you become stronger.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in ankle weights

  5. Seated Opposite arm and leg lift: Same as above, now adding in the opposite arm lift overhead to make this more challenging. Start with repeating this on one side and progress to alternating lifts from side to side.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in wrist/ankle weights

Standing Neutral Exercises:

  1. Standing Neutral: Assume a neutral position. Pay particular attention to the amount of curve in the lower back. Use the abdominal and lumbar muscles to tilt the pelvis into the correct position to assume neutral. Learn to contract the abdominals and back muscles to hold this position while standing and changing postures.

  2. Wall Squat with Neutral: Stand with back to the wall. Keep feet 8-12 inches from the wall. Find neutral and contract abdominals to maintain it. Slowly bend your knees, sliding down the wall several inches and hold this position as long as possible without losing neutral or having pain. Start by performing a shallow squat and progress to a position with thighs parallel to the ground as you become stronger.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in hand weights

  3. Mini Squats with Neutral: Stand away from wall with feet about shoulder width apart. Bend both knees slightly while maintaining neutral. As strength improves, assume a wider stance and squat lower, eventually low enough to lift an object from the floor. Further increase the intensity of this exercise by adding hand weights, then to lifting heavier weight from the ground to waist level.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in hand weights

  4. Standing abdominal side crunches: Maintain neutral. Perform lateral abdominal crunch by squeezing the side abdominal muscles. Think of pulling your ribs toward your hip, performing a small but very controlled motion. Add Theraband for resistance by attaching it to the wall and pulling the resistance across your chest. Move further from the wall to increase the resistance. Also add resistance by holding onto hand weights at your sides as you bend laterally.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in hand weights

  5. Neutral Lunges: Standing, find and hold neutral with abdominal and back control. Step forward about 1-2 feet, landing slowly and gently. Slowly bend both knees to perform a slight squat motion. Return to the start position, and be cautious to avoid arching the back as you step back. Repeat on the same side, then the other side. Progress to alternating from side to side as you get stronger. Further increase the intensity of this exercise by adding hand weights.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in hand weights

  6. Lunges With Opposite Arm Lifts: Same as above, now as you lunge forward and lower down, lift up the opposite arm overhead. Repeat this on the same side, then on the other side. Progress to alternating from one side to the next. Progress further by performing "walking lunges" and perform this exercise as you walk on a flat surface. Add hand weights as you become stronger.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in hand weights

  7. Lunges With Bilateral Arm Lifts: Same as above, now as you lunge forward and lower down, lift up with both arms overhead. Repeat this on the same side, then on the other side. Progress to alternating from one side to the next. Progress further by performing "walking lunges" and perform this exercise as you walk on a flat surface. Add hand weights as you become stronger.

    Start this week with _____ reps/time

    The goal is______

    Add ______lbs. in hand weights