Chapter 18
Therapeutic Exercise for the
Lumbopelvic Region
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Anatomy and Kinesiology
Basic anatomy
L1–L3 similar
L4–L5 similar
Special features of
the zygopophyseal
joints
Changes do occur
with aging
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Osteokinematics/Arthrokinematics
All spinal movements
involve combined
action of several
motion segments
Flexion: 8–13° per
segment
Extension: 1–5° per
segment
Rotation: 1–2° per
segment
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Vertebral Movement During Rotation
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Lateral Flexion
Coupling varies with sagittal position of
segment. Differs among individuals.
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Normal Lumbar Spine Alignment
Line of gravity (LOG)
– ventral to L4
Any displacement of
LOG alters the
magnitude and
direction of moments
on the spine.
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Disc Pressure
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Dynamic Load
All body motion increases load on
lumbar spine.
In a study of normal walking at four
speeds, the compressive loads at
the L3-L4 motion segment ranged
from .2 to 2.5 times body weight.
The loads were maximal at toe-off
and increased linearly with speed.
Capozzo A. Compressive loads in the lumbar vertebral column
during normal level walking. J Orthop Res 1984; 1:292-301.
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Factors influencing loads on the spine
during lifting:
The position of the object relative to the
center of motion of the spine.
The size, shape, weight, and density of
the object.
The degree of flexion or rotation of the
spine.
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General rules to lessen the load on the
spine during lifting
Hold object close to the spine.
Reduce the size of the object.
Bend at the hips and knees and avoid
lumbar flexion/rotation.
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Load transference through the
pelvic girdle
Passive and active mechanisms.
Passive mechanisms contribute to form
closure.
Active mechanisms contribute to force
closure.
The SIJ relies on both form and force
closure mechanisms for stability.
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Factors Contributing to Form Closure
The shape of the joint surface.
The friction coefficient of the articular
cartilage.
The integrity of the ligaments that
approximate the joint.
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Pelvic Girdle
Sacroiliac joint (SIJ) anatomy is highly
variable.
The articular cartilage lining the SIJ is
unusual.
The sacral surface is lined with smooth
hyaline cartilage whereas the iliac surface is
lined with rough fibrocartilage.
This articular combination contributes to form
closure at the SIJ.
Strong complex ligaments contribute to both
form and force closure.
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Osteo/Arthrokinematics
Individual variability in joint anatomy and
kinematics in early, middle, and late ranges of
movement.
Movement does occur at the SIJ.
The most widely accepted movements are
nutation and counternutation.
No definitive model exists to define the PICR of
the joint.
Anterior and posterior iliosacaral rotations
occur as do vertical movements with limb
loading.
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Nutation and Counternutation
Nutation is sacral flexion in which the base
of the sacrum moves anterior and inferior
and the apex moves posterior and superior.
Counternutation is sacral extension in
which the base of the sacrum moves
posterior and superior and the apex moves
anterior and inferior.
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Kinetics
Stability is crucial!
Pelvic girdle transmits forces from weight of
head, trunk, and upper extremities downward
and forces from lower extremities upward.
The angle of inclination of the articular surface of
the sacrum is a significant factor in the stability
of the SIJ.
Vertical-oriented SIJs subject ligaments to
greater stress.
Asymmetric loading may occur with LLD.
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Myology
Optimal function of force closure mechanisms
requires integration of posterior and anterior
muscles of the spine and pelvis.
Due to multiple attachments, thoracolumbar
fascia (TLF) plays a significant role in
stabilization.
29 muscles originate or insert into the pelvis.
Significant forces can be generated by various
combinations and require significant counterforces for stabilization.
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Myology
Posterior
Latissimus dorsi
Erector spinae
Multifidus
Quadratus lumborum
Interspinalis
Intertransversarii
Anterior
External oblique
Internal oblique
Transversus
abdominis
Iliospoas
Rectus abdominis
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Myology
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Deep ES Vector Forces
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Examination and Evaluation
Three critical questions must be answered:
1. Is there a systemic or visceral disease for the
source of referred pain into the back or lower
extremities?
2. Is there evidence of neurologic compromise
that represents a surgical emergency?
3. Are there mechanical findings that guide
conservative management?
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Examination and Evaluation
Patient history – Critical! Can begin clinical
reasoning toward diagnosis.
Screening exam – Helps to determine if
symptoms from lower quadrant are
originating from lumbopelvic region.
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Screening Exam
1.
2.
3.
4.
5.
6.
7.
Observation – Posture scan in standing and sitting.
AROM – In both standing and sitting.
Stress tests – Performed on both lumbar spine and
SIJ.
Provocation tests – Prone posteroanterior pressure
to the lumbar spine.
Palpation – Assess tone changes, lesions, pain
provocation.
Dural mobility tests
Neurologic tests – Key muscles, reflexes,
dermatomes.
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Tests and Measures
1.
2.
3.
4.
5.
6.
7.
8.
9.
Anthropometric characteristics
Ergonomics and body mechanics
Gait/balance
Muscle performance
Neurologic testing
Pain
Posture
ROM, muscle length, and joint mobility
Work, community, and leisure integration or
reintigration
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Think about what tests you
would include in each category
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Anthropometric Characteristics
May be a risk factor for developing certain types
of lumbopelvic syndromes.
Example: Male with broad shoulders, narrow
pelvis, and high center of mass is more prone to
lumbar flexion forces.
These characteristics may be difficult to
compensate for with a job requiring repeated
bending movements.
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Ergonomics and Body Mechanics
 An assessment of a patient’s job-related duties and
physical demands is critical to a positive outcome.
Include assessment of:
 Materials handling
 Lifting mechanics and capabilities
 Non-materials handling such as sitting or standing
tolerance
 Workstation ergonomics
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Gait and Balance
Gait is a complex functional movement pattern
that can indicate pathomechanical factors
contributing to lumbopelvic signs or symptoms.
Video analysis can be an efficient tool to
evaluate the complex interaction of multiple
regions on the lumbar spine during walking or
running.
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Muscle Performance
 Force- or torque-generating capability of spinal extensor
or abdominal muscles via MMT.
 Interpret isokinetic testing of trunk muscles with caution.
 Test muscle performance of deep trunk muscles (i.e.,
TrA, LM) via specific stability tests using active
movements of the extremities.
 Interpret resisted tests to provoke pain in contractile
tissues with caution.
 MMT of pelvic girdle and pelvic floor muscles
can provide pertinent information.
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Neurologic Testing
A thorough neurologic examination for the
lumbopelvic region consists of 3 parts:
Upper motor neuron screening – Upper
lumbar central herniation only
Neuroconductive testing – Sensory, motor,
DTR changes
Neurodynamic tests – SLR, PKB, slump
maneuver
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Pain
Measurement of pain as it relates to disability
(i.e., use of pain scales).
Examination to determine that lumbopelvic
region is the source of pain.
Examination to determine cause(s) of pain.
Examination to determine physiologic impact of
pain.
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Posture
Casual observation of standing or sitting posture
when patient is unaware.
Specific standing, sitting, and recumbent
posture.
Develop hypothesis regarding relationship of
posture to pathomechanical cause of the pain.
Develop hypothesis regarding muscle length
and its contribution to pathomechanical cause of
pain.
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Range of Motion, Muscle Length,
and Joint Mobility
 ROM of lumbar spine, thoracic spine, pelvic–femoral
region, and relationship between all regions and the
lumbar spine.
 Muscle extensibility tests across pelvis and hips as well
as lumbar spine.
 Specialized McKenzie testing.
 Joint mobility including PPIVM, PAIVM, and segmental
stability testing of lumbar spine and pelvis.
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Work, Community, and Leisure
Integration or Reintegration
Measurements of disability such as:
Oswestry Low Back Disability Score
Million Visual Analogue Scale
Roland Morris Disability Questionnaire
Waddell Disability Index
Clinical Back Pain Questionnaire
Low Back Outcome Score (LBOS)
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Therapeutic Exercise for Common
Impairments
Aerobic capacity impairment
Balance and coordination impairment
Muscle performance impairment
Range of motion, muscle length, and joint
mobility impairment
Posture and movement impairment
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Aerobic Capacity Impairment
Can be considered a secondary condition
resulting from incapacitation associated with
CLBP.
Choose activity that does not increase pain.
Benefits of aerobic conditioning include:
Enhanced healing
Weight loss
Favorable psychological effect
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Balance & Coordination Impairment
 There is proven functional importance of proprioceptive
training during rehabilitation of the spine.
 True stability of the spine at the skill level requires
precise and rapid responses to perturbations in the load
imposed on the spine.
 LBP patients have a tendency to fulcrum at hips and low
back to maintain balance.
 Gym balls, wobble boards, slide boards, and
foam rolls can be used to train
propioception.
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Balance Impairment
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Muscle Performance Impairment
Muscle performance impairment can
result from any of the following
mechanisms:
 Muscle strain
 Pain
 Inflammation
 Neurologic pathology
 General deconditioning
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Exercise for Muscle Control
Research has established a link between lumbar
dysfunction and function of the inner core
muscles.
Inner core muscles include:
Transversus abdominis (TrA)
Lumbar multifidus (LM)
Pelvic floor muscles (PFM)
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Exercises for Inner Core Control
Choose exercises that promote optimal lengthtension properties of the trunk and pelvic girdle
muscles.
Consider specificity of training (i.e., stability
versus torque production).
Consider the stage of motor control.
Patient-related instruction is critical to successful
outcomes.
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Exercise for Muscle Control
Inner Core
TRA, LM, PFM
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Underlying Premises for Justifying
Exercises for Inner Core
General strengthening programs for the trunk
muscles may not adequately recruit or improve
the performance of the inner core.
Localized and specific exercise aimed at training
neuromuscular control of the inner core may be
critical to improving subtle patterns of muscle
recruitment necessary for optimal segmental
stability of the lumbar spine.
Include gluteus medius/maximus, deep hip LRs,
latissimus dorsi for optimal pelvic stability.
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Progression Criteria from Core Training
1. Lumbar spine should not deviate
from initial starting position (neutral
position).
2. Trunk muscles should be
functioning at optimal lengths.
3. Rectus abdominis (RA) should not
be dominating synergy, and
valsalva maneuver is discouraged.
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Supine Inner Core Progression
FIRST, SET LUMBOPELVIC CORE!
Level I: Single leg slide
Level II: Single leg lift until hip is at 90 degrees with
floor. Follow with level I, sliding one leg to
extended position.
Level III: Level II with single leg glide instead of slide.
Level III: Bilateral leg lift to 90 degree position, double
leg slide.
Level IV: Level III but with double leg glide.
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Inner Core Series
This is a series of activities designed to recruit the
core, aided by superficial muscles as needed, in
a variety of positions:
 Supine inner core series
 Stomach-lying elbow lift
 Quadruped arm lift
 Sitting knee extension
 Activities of daily living
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Higher levels of stability
After neuromuscular
control and functional
levels of muscle
performance are
established,
additional resistance
can be added to
progress to higher
level functional
activities.
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Neurologic Impairment and Pathology
Underlying mechanical or biochemical
irritation must be treated first.
SPECIFIC exercises to improve
stability of offending segments/regions
can reduce stress on nerve root.
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Muscle Strain
Can be the result of:
Trauma – Teach patient how to avoid
postures and movement patterns that
continue to irritate the injured segment(s).
Overuse – Improve force/torque production
of underused synergistic muscles
(timing/balance).
Gradual elongation – Support overstretched
muscles in shortened range.
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General Disuse and Deconditioning
Commonly develop from general lack of
activity.
Sit Up
2-Phase Activity:
I – Primarily trunk flexion with pelvic tilt (IO
and RA)
II – Hip flexion phase (EO recruited to
neutralize forces on pelvis from hip flexors)
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Sit Up
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Modification for Short Hip Flexors
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Range of Motion, Muscle Length, and
Joint Mobility
Clinical decisions regarding exercise
prescription for ROM, muscle length, and
joint mobility must be considered in
relation to other regions of the spine,
upper quarter, and lower quarter.
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Hypermobility
Four factors can be responsible for the
development of a hypermobile segment:
Trauma
Pathology (e.g., rheumatoid arthirtis)
Anatomic impairment (e.g., spondylolisthesis)
Repetitive movement patterns
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Relative Flexibility or Stiffness
Sahrmann term for site of abnormal or excessive
movement.
In a multijoint system with common movement
directions, any given movement follows the
segments that provide the least resistance,
resulting in abnormal or excessive movment of
segments with the least amount of stiffness.
With repeated movement over time, the least
stiff segments increase in mobility and the more
stiff segments decrease in mobility.
Sahrmann AS. Diagnosis and Treatment of Movement Impairment
Syndromes. St. Louis, Mosby, 2002.
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Hypermobility
 Improve mobility at sites/segments of relative stiffness.
 Movement training should be based on protecting the
specific direction susceptible to movement (DSM).
 Sites of relative flexibility should be protected from
excessive or repeated movement during exercise and
ADLs.
 It may be necessary to immobilize lengthened muscles
in shortened range (e.g., abdominal binder).
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Exercise Example to Treat Relative
Flexibility at the Lumbar Spine
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Hypomobility
To be most effective, activities or techniques to
reduce hypermobility must occur
simultaneously with activities or techniques to
increase mobility.
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Interventions for Hypomobility
Articular joint
mobilization
Muscle energy
techniques
Soft tissue
mobilization
Self mobilization
AAROM
AROM
PNF
Passive stretching
Active stretching
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Neuromeningeal Hypomobility
Loss of mobility of the nervous system can
occur as a result of congenital disorders,
trauma, surgical complications, or
degenerative changes.
Two types of neuromeningeal hypomobility:
Tethered cord syndrome (contraindication to
physical therapy intervention!!)
Nerve root and dural movement dysfunction
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Neuromeningeal Mobilization of the
Lower Quarter
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Pain
The physical therapist is most interested in the
mechanical cause of pain as it relates to movement.
 Instruct patient in postures and movements that
reduce or alleviate pain and avoid postures and
movements that increase pain.
 Improve mobility in hypomobile segments and
stability in hypermobile segments.
 This allows painful structures to “rest” and reduce or
halt the inflammatory process.
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McKenzie Approach to Treatment
of LBP
Use movements that reduce or abolish
symptoms.
Understand concepts of peripheralization and
centralization.
Annular fibers must be present to exert force on
the NP.
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Sample McKenzie Technique
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Posture and Movement Impairment
Educate patient in postures and basic movement
patterns that avoid reproducing symptoms.
 Bed mobility
 Sit to stand
 Bending
 Lifting
 Stairs
 Gait
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Proper Bending Pattern
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Common Diagnoses
 Lumbar disc herniation
 Spinal stenosis
 Spondylolysis and Spondylolisthesis
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Lumbar Disc Herniation
If the annular tear progresses to full
annular disruption, a herniated nucleus
pulposus (HNP) results.
Clinically, disk herniation can be divided into the
following subsets:
 HNP without neurologic deficit
 HNP with nerve irritation
 HNP with nerve root compression
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LDH Treatment – Acute
Medications are often prescribed by referring
provider.
Controlled rest with posture and activity
modification.
Avoid flexed and asymmetric postures.
Basic movements (core training–heel slides).
Soft tissue mobilization and passive
stretching may decrease pain associated
with spasm.
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LDH – Subacute and Chronic
Treatment should focus on altering postures and
movements and associated impairments that
produce symptoms.
Patient-related instruction is most important
intervention to provide patient with decisionmaking tools to protect against developing
chronic disability.
Self-management exercises are emphasized.
Invoke confidence in self management of back
pain.
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Spinal Stenosis (SS)
Abnormal narrowing of spinal canal
(central) or intervertebral (lateral)
foramen.
Hallmark signs and symptoms:
Increased pain upon extension
Pain in legs
Pain may increase during coughing or
sneezing
Pain alleviated with flexed postures
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SS Treatment
Improve core muscular performance.
Lengthen hip flexors contributing to
anterior pelvic tilt.
Shorten and strengthen thoracic
musculature to correct kyphosis.
Use unilateral exercises if asymmetry
exists in pelvic girdle and lower extremity
(possible scoliosis).
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Spondylolysis and Spondylolisthesis
 Spondylolysis – Bilateral defect in pars interarticularis.
 Spondylolisthesis (5 classifications) – Forward
subluxation of the body of one vertebrae on the
vertebrae below it.
 Type I – Isthmic
Type IV - Elongated
 Type II – Congenital
pedicle
 Type III – Degenerative Type V - Destructive
disease
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Interventions for
Spondylolysis/Spondylolisthesis
Bracing
Nonsteroidal anti-inflammatory medications
Avoid extension exercises
Avoid exercise, postures, and movements
that place shearing forces on the spine
Strong emphasis on core strength
Exercise, posture, and movement retraining
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Adjunctive Interventions – Bracing
Bracing is indicated when exercise alone, used
to improve segmental stability and relative
flexibility, has failed to produce a desirable
functional outcome.
External support can provide stiffness to
relatively flexible segments, thus providing
opportunity for relatively stiff segments to begin
to move.
May also provide support to overstretched
muscles (I.e., external obliques).
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Adjunctive Interventions – Traction
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Summary
 Thorough understanding of anatomy and
biomechanics is crucial!!!
 Exercises are based on systematic
examinations identifying the physiologic
and psychological impairments most
closely related to the individual’s functional
limitations and disability.
 Exercises should be related to the
pathomechanical cause of lumbopelvic
conditions.
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Summary (cont.)
 Exercise management of common
patho-anatomic diagnoses must not
follow a recipe approach, but rather
relate to the patient’s unique
impairments, functional limitations, and
disability.
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